The Department of Health is creating local groups to design an emergency disaster preparedness plan for pandemic flu and other emergencies that would impact pregnant women and newborns, since they are a vulnerable group and need to be treated differently. In our county, it has been decided that healthy pregnant women will deliver outside the hospital in some emergency situations, pandemic flu being one of them. Are we prepared to assist these women and their newborns?
Childbirth is a natural, physiological event. It is not, by definition, a medical emergency that needs to be “managed”, nor is it an illness that needs to be “treated”. Women’s bodies are created and designed to give birth, and the majority of births are normal. (This article only deals with normal childbirth. Please see Challenges in Childbirth for situations outside of normal.) If you suspect that you may be called upon to assist at a birth, prepare and educate yourself as best as possible. Please see the list at the end of this article for my favorite references.
Be Prepared to Assist
Before you go to the mother’s home, gather the following items to take with you:
Clean bath towels–as many as you can spare, and then some (you will get them back)
Clean hand towels–as many as you can spare, and then some (you will get them back)
Clean face cloths–six or so
Clean set of large, flat bed sheets
Plastic sheet or clean shower curtain
Plastic garbage bags–both small and large.
Sterilized scissors–fabric scissors work the best, but other scissors or a razor blade is also OK.
Clean shoelaces, new if possible. If not, boil them for 20 minutes to sterilize.
Sterile surgical gloves–at least three pairs, six is better
Clock or watch, preferably with a second hand
Notebook and pen
Non aspirin pain killers–Ibuprofen is good
Other items that are very nice to have during a birth and postpartum are: Chux brand disposable absorbent mattress pads (about 20), adult diapers (about 10), sanitary napkins (overnight style), bulb or ear syringe (boiled for 45 minutes to sterilize), receiving blankets for baby, knit beanie-style hat for baby, scale (fish scale is fine), pliable tape measure.
You should be freshly showered, hair washed and tied back, and have on clean clothes before you go over. Have trimmed finger nails and do not wear any rings. Bring a trusted friend (two are better), someone you would trust at your own birth.
Preparing the Birth Bed
The laboring mother needs a clean, private place to have her baby. If a bed or a mattress is available, and if you have enough time, prepare it for childbirth as follows:
Take the sheets off the bed and put clean sheets on, preferably her sheets.
Lay the plastic sheet (or a shower curtain) over the clean sheets.
Put another set of clean sheets on the bed, over the shower curtain.
Put blankets, comforters and/or the bedspread on the bed.
Remove the pillow cases and put clean pillow cases on the pillows.
Put a plastic garbage bag on the pillows, over the pillow case.
Put another pillow case on the pillows, over the garbage bag.
If no bed or mattress is available, then lay plenty of blankets on the floor for comfort, then the first set of sheets, the shower curtain, the second set of flat sheets and finally the comforter/bedspread. If there is no time to make the birth bed, put several clean bath towels under her.
The room should be clear of clutter (at least on the floor around the bed), darkened (not black, think ‘romantically dim’) and warm. Line a small or medium size garbage can with a plastic garbage bag and keep it close by. Put on a pot of water to boil, let it boil for 20 minutes, keep it covered and let it cool.
Early Signs of Labor
As her body prepares for labor, the mother will notice several changes. She may pass a “mucous plug” when she goes to the toilet. This generally looks like a large blob of snot and will sometimes have a bloody streak. This is no sign of trouble, just a sign that her body is getting ready.
Her water may also “break”, or just “spring a leak”. The amniotic fluid (water) is usually clear and odorless, which is a good way to know the difference between that and urine. Green amniotic fluid can mean the baby needs to be born quickly. Record in your notebook the date and time her water broke and what color it was.
She may also feel “crampy”, grouchy and just ‘out of sorts’. All of these are good signs that labor is close.
LABOR (the first stage)
Labor is divided into three stages, with each stage having several phases. Stage 1 is where the cervix is thinning and dilating to about 10 centimeters to allow the baby to pass through the birth canal. Labor can start and stop several times as phase 1 of stage 1 gets started. This start-and-stop phase (the latent phase) can last several hours, several days or a week or more, especially if this is the mother’s first baby. Encourage the mother to continue her normal daily activities as much as possible during the early stages of labor. As long as she can walk and talk through a contraction (labor pain), she is still in the latent stage. (Many women go to the hospital at this stage in labor, only to be examined and sent back home.) When she can no longer walk and talk through a contraction, she is in active labor. Most women want someone with them at this point and this is when you will go to her home. Once you are there, scrub your hands with anti-bacterial soap for at least 10 minutes. Scrub extra well under and around your finger nails. If you don’t have any sterile gloves, scrub vigorously with a brush up to your elbows for 20 minutes. Make a note in your notebook of the date and time she went into active labor.
During active labor, you take on a supportive and protective role. If her husband or significant other is available, include him in this circle of support. Grandmothers, sisters and friends can be a wonderful source of support, also. Be aware of any negative energy around her–if someone is negative, non-supportive or critical, you may need to dismiss them to another room. (You can ask them to make a big pot of stew, run to the store, take care of the older children, go get something, etc.)
Labor is called “labor” for a reason–it’s work. Give the mom-to-be a lot of support and comforting words like, “You’re doing a good job”, “You can do this”, and “We’re right here”. Even just counting the seconds of the contractions can be enough. Some women want it quiet during a contraction, others need to hear voices. Some women will labor quietly, others will moan, hum, sing, grunt or even cry. Let her do what she needs to do, and honor her need for quiet or vocalization. She should be encouraged to drink water and use the toilet regularly, and eat snacks to keep her energy up. She should also walk if she wants to, or change positions. Many women like to labor on their side with a pillow between their legs, on all fours, or while squatting next to the bed. Laying flat on her back is the worst position to labor in, both for mom and baby, and should be discouraged. Some women will vomit, pass gas or have a bowel movement during labor. All this is normal–reassure her, and clean up any messes promptly.
If the mother is not prepared for an un-medicated, out-of-hospital birth, then your job may be a little more intense. The mother may scream, hit, bite or thrash. She will mostly like curse and swear and say things to her husband she will regret. She may demand drugs or even a C-Section. (Even those who plan a home birth will sometimes do this.) It is extremely important that you remain calm at all times! Do not take offense, do not reprimand or scold, protect yourself and those around you from physical harm, and protect the mother also. You (or her husband) may need to get right in her face to help her refocus.
Keep the birth bed as clean as possible, changing the towels or Chux pads regularly when they get soiled. Place all dirty linens in a plastic garbage bag to be washed later, put all disposable garbage in a separate garbage bag.
Labor can be long and sometimes the mother will fall asleep in between contractions. Be very quiet and let her sleep. The next contraction will wake her up (if she is having difficulties dealing with the contractions, wake her up about 10 seconds before the next one starts). The last 2 centimeters of dilation are called “transition” and are the most intense. Many women will have a difficult time during transition and will need your undivided attention and lots of support. When the cervix is fully dilated, transition is complete and the baby is ready to move down into the birth canal. The body knows the real work of labor is about to begin and often times contractions will stop for 10 or 15 minutes. This is normal and the mother should be allowed to rest or (preferably) sleep. No one in the room should talk or even move during this time. Some women don’t have this break and immediately feel the urge to push. Make note in your notebook of the date and time she felt the urge to push.
DELIVERY (the second stage of labor)
Most women will have an urge to push when the time is right. She should follow that urge and push until it feels good. Labor is work, but pushing is rewarding–she can actually do something about those contractions. There is no need to push until she is blue in the face; she needs to continue breathing and just following her body’s rhythm. The urge to push is also your cue to have someone put all the towels in the dryer or next to the fireplace/heater to warm them up. Put on a fresh pair of sterile gloves (or wash your hands again) and put a fresh towel or Chux pad under her. Encourage her to “open up”. Open her mouth and open her legs to let her baby through. If the area needs to be cleaned, use your boiled and cooled water and a clean washcloth to wash the vaginal opening and surrounding area.
As the baby moves down, remember that it’s ‘two steps forward, one step back’. It’s normal for the baby to move back up a little after a contraction. Check periodically to see if you can see the head. When you do, be sure to announce it to the mom so she will know there is progress. When you can see the head, it’s time to get her on the bed and ready for the delivery (if she’s not already there). Unless you–or the mother–are experienced in other birthing positions, I recommend she semi-sit on the bed with someone sitting cross-legged behind her for support (the support person should be sitting against the headboard or a wall). You need to be at her bottom, others can be on either side of her. If the bed is long and you are having trouble being where you need to be, have her lay sideways on the bed. Have your towel person ready to bring you three warm bath towels and have them ready and waiting when the baby is born. If it is dark, have someone hold the flashlight for you so you can see baby as he is being born.
As the baby moves down, the skin and muscle tissue around the vaginal opening will stretch and stretch. Support the perineum by applying gentle pressure with a gloved hand on the perineum as the head comes down. This will help prevent tearing. It is important that the baby’s head be born gently and slowly. Do not blast the baby out or you will have a very torn mother (with possibly no one to suture her). Some babies are naturally slow in emerging, other times the mother will need to blow through a few contractions to ease that baby’s head through. Do not rush this part, as exciting as it may be. After the head is born, check around his neck with your gloved finder for the umbilical cord. If you find the cord around his neck, unwrap it before the next contraction and before he is born. If there was any green when the water broke, suction the baby’s mouth and nose now to prevent him from inhaling any meconium (the green stuff, which is actually the baby’s poop). (Squeeze the bulb syringe away from baby, then insert syringe into baby’s mouth and nose and release your grip to suction. You never want to squeeze the syringe while in baby’s mouth or nose. Take the syringe out of baby’s mouth and squeeze again into a towel to get the gunk out before doing it again.) After the head is born and before the body is born, some babies will open their eyes and look around. This is normal and there is no need to rush. Most of the time, the shoulders and body will be born the next contraction with a satisfying push. Make a mental note of the time baby was born (or have someone watch the clock) so you can record it in your notebook.
Immediately after the birth
Once the baby is born, immediately put him on his mother’s belly, face down, skin to skin and cover both of them with a warm towels just out of the drier. Do not cut the cord! (Babies get 30% of their blood supply after they are born through the umbilical cord. The umbilical cord also supplies oxygen.) Pay very close attention to him to make sure he takes his first breath. If baby is unresponsive after a few seconds, use a dry towel and rub his back briskly. Make sure his mouth and nose are clear. If he is “juicy” use a bulb syringe to suction out some of the mucous. Position him on mom’s belly so that his head is lower than his bottom so that gravity will drain fluids. More than 90% of newborn babies take their first breath spontaneously or with minimal stimulation.
Gently born babies seldom scream and some do not even cry. Keep rubbing his back, then his chest until he has taken several good breaths. Once he is breathing well, mom can bring him up to her chest (skin to skin to keep baby warm) and get a good look at him. Cover both mom and baby with warm towels and blankets. Encourage her to touch her baby and talk to him–do not disturb this initial bonding time if at all possible. Babies are usually born a purplish color and their heads can be an odd shape due to the molding that happens during birth. As mom and dad bond with their new baby, watch and listen to baby. (Have someone else monitor mom’s blood flow.) He should be pinking up and his lungs should be clearing up. If you hear a rattle or gurgle, use the bulb syringe again. Keep stimulating if necessary. If you have a knitted baby hat, put it on him. The baby may be have white, sticky stuff on his body. This is called vernex and should not be washed or wiped off. Let it soak in or rub it in, even. It is Mother Nature’s best body lotion and prevents peeling later on (older midwives will often take some for themselves).
Once you have baby stabilized, turn your attention to the umbilical cord and the placenta (afterbirth). Grab the cord with your thumb and two fingers to feel for a pulse. Once the umbilical cord has stopped pulsating, it is safe to cut. Use clean shoelaces and tie one lace a good inch or two away from baby’s navel. (This can be done while baby rests in his mother’s arms.) Use the other lace and tie it further away from baby, about an inch away from the first tie. Tie the laces as tight as you can! Take your sterilized scissors or razor blade and cut between the two shoelaces (or have the new dad do this). There are no nerves in the umbilical cord, so you will not hurt the baby. The cord is tough, though, and you might be surprised at the bit of work required to cut it. Some cultures put gauze and tape over the freshly cut cord. Unless you have Goldenseal or other drying agent, this is not recommended and can result in a rotting cord stump. Baby is now ready to be put to the breast, if he hasn’t already done so.
The mother may start to shake a few minutes after the baby is born, this is a normal reaction to childbirth. Cover her with more warm towels or blankets to keep her warm, and monitor her blood flow. Encourage the mother to start breast feeding her baby as soon as possible. This will not only comfort baby, but breast feeding releases a hormone that will help the uterus contract. An experienced mother will need little assistance, but a new mother may be unsure of herself. The general rule is “belly to belly, mouth to breast”. Have mom sit up and position baby in the crook of her arm, with his belly right next to hers (he should not have to turn his head to get to the breast). Help baby get a full mouthful, not just the end of the nipple. Teasing the top of his mouth with the nipple will usually get his attention. Let him nurse until he is satisfied, but don’t pull the breast out of his mouth (that’s painful for mom!). Have mom put a finger in her baby’s mouth to break the seal, and then take her breast away. Give him the other breast if he wants it. She will usually feel contractions while breastfeeding and this is a good thing.
Massaging the fundus
Continue to monitor her blood flow and check her fundus (the part of her belly above the pubic bone, where her uterus is). You want to feel a firm lump there, like a grapefruit, to know that the uterus is clamping down and getting ready to expel the placenta. If the bleeding is more than a trickle after a few minutes, massage the fundus. Push down and around (a little like kneading bread) until the uterus contracts and you feel that firm lump. You may need to do this every few minutes if the uterus is “soggy”.
EXPULSION OF THE PLACENTA (the third stage of labor)
Even though the baby has been delivered, the mother will still have mild contractions. Ideally, the placenta should be delivered within 30 minutes of the baby, and most of them are. Have a pan, mixing bowl or plastic garbage bag ready to receive the placenta. Hold the cord tautly (do not pull) and ask the mother to “give a little push”. If the placenta is ready, it will slip right out and into the bowl. If it doesn’t come out, wait 10 minutes and try again. Take the placenta into another room, it can be buried later. It is the expulsion of the placenta (more than the birth of the baby) that can cause a hemorrhage. Be very aware of blood loss immediately after the placenta has been expelled. A small gush of blood (a cup or so) and some trickling of blood is normal. A large gush or a continuous flow of blood is not.
After baby has nursed and before he is dressed, you will need to weigh and measure him. This can be done on the bed with parents and friends present. Use a bathroom scale (have someone hold him), or wrap him in a lightweight receiving blanket and hang the blanket on a fish scale. Record his weight in your notebook. Then take the tape measure and measure from the crown of his head to his heal. You will need to stretch him out straight to do this, and most babies don’t like this. Be sure to explain to him what you are doing so he does not feel fear. A full-term baby will be between 18-21 inches long. Record this in your notebook. Measure around his chest, across his little breasts, and around his head just above the eyebrows. Record these measurements also. Visually inspect him, count fingers and toes and look him over for anything unusual. Dress him, put his hat back on and wrap him in receiving blankets.
Postpartum (the unofficial fourth stage of labor and delivery)
The baby has been born, the placenta has been delivered, baby has been fed and mother and baby are stabilized. It’s time to clean up. Have mom sit at the edge of the bed, and put her feet on the floor. She may feel dizzy doing this, have her take a minute to acclimate before standing up. Help her stand up, or have her husband help her. Have her stand there for a moment before starting to walk. Walk right with her to the shower. Have someone follow behind her, ready to catch her should she fall or feel like fainting. Stay near her while she showers. She should try to urinate. After she is out of the shower, help her dry off, put a clean adult diaper or two sanitary pads and a clean nightgown or pajamas (with buttons down the front for easy nursing). Comb her hair and tie it back for her. She needs to feel pretty.
While the mother showers, have someone glove up and strip the top sheet of bed sheets and shower curtain and the top pillow cases and garbage bags, leaving the second clean set of sheets. (If there was not time to make the birth bed, strip the sheets and put on clean sheets and pillow cases.) Put all linens and soiled towels in the washing machine, add detergent and bleach, and start the machine. (If there is no electricity, put them in the bathtub when it is available.) Put all Chux pads, used gloves and any other disposable supplies in a plastic garbage bag and tie it shut.
If the mother has lost a lot of blood, it may not be a good idea to have her get up and walk. See if she can pee into a clean pad or towel. Clean her with your boiled and cooled water and a clean wash cloth, washing her face and neck first. Change the water, get a new washcloth, then wash the vaginal opening next, then her bottom, thighs, belly and legs. Put on a clean adult diaper or two sanitary pads and help her into a clean nightgown or pajamas. Have her roll to one side of the bed while you strip the other side, rolling it up next to her. Roll her over to the clean side of the bed while you finish stripping the other side. Comb her hair and tie it back for her.
Stay with her for three or four hours after the birth. If the after pains are uncomfortable, she can take Ibuprofen. Let her and her family sleep, but check her sanitary pads every hour. She should be bleeding like a normal heavy period. Use this time to record more details of the birth in your notebook, do laundry and finish cleaning up. Double bag the used supplies (chux pads, gloves, etc) and tie it tight. Check mom and baby one more time before you leave. Baby’s hands and feet should be warm, and she should be pink. Her color should be good, too, and she should be able to urinate. After four hours, the dangers of hemorrhage are mostly passed and you can go home and get some much deserved rest.
About The Author: Kelli is a Midwife’s daughter, birth assistant, mother of home-birthed children and business owner. She has worked with over 500 midwives across the USA.
Spiritual Midwifery, Fourth Edition by Ina May Gaskin. It’s a ‘hippy book’ with lots of natural birth stories as well as good solid information regarding out-of-hospital childbirth.
Gentle Birth Choices, by Barbara Harper and Suzanne Arms. Includes a DVD of six live gentle births.
Newborn Breath — Web site of Karen Strange–she teaches newborn resuscitation classes all over the USA and abroad. These classes are for out-of-hospital birth, anyone can attend.
The web site of the Midwives Alliance of North America.
Independent Midwives UK — A site for locating a midwife in the UK.
CanadianMidwives.org–to locate a midwife in Canada.
Citizens for Midwifery–to locate home birth midwives in the USA.
MidwivesAustralia.com.au–to locate a midwife in Australia.
Dona.org–Locate a doula in your country, or take a class yourself. Doulas are great birth assistants.
MEACSchools.org–to locate an accredited midwifery school in the USA. They often offer classes or courses that non-matriculated students can take. It is also a good resource to find student midwives in your area.
LaLache League — a great resource for helping mothers to breastfeed.