EMERGENCY CHILDBIRTH

When a woman is ready to give birth, the contractions of labor are usually intense and uninterrupted, or separated by intervals of less than 3 to 5 minutes. If the child to be born is not the woman’s first, labor can progress very quickly, so don’t wait until the last minute to set up. On the other hand, don’t deliver a baby in the woods if it isn’t necessary. If the child is the mother’s first, if the contractions are more than 5 minutes apart, if the waters have not “broken” (a gush of fluid from the ruptured amniotic sac) and there has been no passage of bloody mucus, and if no bulging is present in the vaginal area, consider whether you have time to make it to the hospital. If the waters have broken and labor has not begun, it is best to evacuate the mother, because delivery must occur or be induced within 24 hours to avoid the onset of an infection that could jeopardize the infant and mother. If the umbilical cord or any other part of the infant other than the head is showing at the vagina, the delivery will be difficult and should be performed if at all possible by a skilled obstetrician.

If delivery is imminent (the mother wishes to push) and you are outdoors, spread a towel or blanket. The birthing process is fairly messy, so don’t expect to salvage the ground cloth. Wear sterile latex rubber gloves from your first-aid kit. If you are allergic to latex, use other nonpermeable gloves (such as nonlatex synthetic). If you don’t have gloves, wash your hands with soap and water. Have the following supplies ready: four towels for drapes; two sturdy strings to tie the umbilical cord; a sharp pair of scissors, scalpel, or knife to cut the umbilical cord; a towel to dry the baby; a blanket to wrap the baby; a rubber suction bulb for the baby’s mouth and nose; and a large plastic bag to carry the placenta.

Have the mother undress below the waist and cover her with a blanket or sheet. She should lie on her side between contractions until she feels that she is ready to push. When she wants to push, have her lie on her back with her legs spread as far apart as possible. Place a towel (drape) over each thigh, across the abdomen, and under the buttocks to “frame” the vagina.

It is extremely helpful to elevate the buttocks with a folded blanket or pile of towels. This is because the most difficult part of a normal birth is delivery of the upper shoulder, which is facilitated by pushing the infant downward at the proper time.

When the mother is undergoing a contraction, and you see some wrinkled skin and a wisp of hair from the infant’s head showing in her vagina, have the mother grab behind her legs and pull them up toward her head, or plant her feet firmly, while she bears down (like having a bowel movement) and pushes. This may go on while the vaginal entrance stretches to accommodate the infant’s head. If the fluid-filled, transparent amniotic sac is bulging out in front of the infant’s head, it can be nicked with a sharp blade or scissors to allow the fluid to be released and the delivery to proceed. Do not do this unless you are absolutely certain that the childbirth will occur away from a hospital. A mother may prefer to squat during delivery, but this makes assisting her more awkward.

During a push, put one hand gently on the infant’s head and another underneath his head, providing countertraction against the woman’s perineum (the area between the anus and the vaginal opening) to allow gradual stretching of the opening and to then assist delivery of the head and control the speed of delivery. You do not want the head to “pop out,” to avoid a large tear in the vagina.

A baby is delivered in (ideally) two stages. First, the head and face appear, usually with the face down (Figure 104). Once the infant has appeared to the level of his eyebrows, instruct the mother to stop pushing. The baby will be extremely slippery. When his face appears, run your fingers around the infant’s neck to see if the umbilical cord is wrapped around it. If it is, see if you can slip it over the head. If not, tie (clamp) it off tightly twice, with about 1 ½ in (3.8 cm) between ties, and cut carefully between the ties. The ties must be tight and not slip off, or the baby could suffer severe bleeding.

Figure 104 Appearance of the head and face during childbirth.

In the moment between the delivery of the head and the beginning of the shoulders’ emergence, support the head with one hand and gently wipe the face with a clean cloth. Gently suction the nose, using the bulb syringe, by squeezing the air out, placing the tip in each nostril, and letting the bulb inflate. Squirt out any extracted material before each insertion of the tip. Suction each nostril at least twice, and then suction out the mouth. If a device for suction isn’t available, wipe out as much amniotic fluid as you can with a finger, tissue, or cloth.

The baby’s head and body will spontaneously rotate 90 degrees (don’t twist them) to one side as the body starts to emerge. Have the mother resume pushing. While supporting the head, grasp the uppermost (with respect to the ground) shoulder and apply gentle downward pressure until the upper shoulder is delivered from the vagina (Figure 105). Don’t tug on the head or pull from underneath the infant’s armpits. After the upper shoulder is out, exert gentle upward pressure to free the lower shoulder (Figure 106). At this point, be prepared to hang on tight, because the rest of the baby will shoot out, usually with a big gush of amniotic fluid and some blood.

Figure 105 Gentle downward pressure to deliver upper shoulder.

Figure 106 Gentle upward pressure to deliver lower shoulder.

Hold the baby in a towel or blanket and dry him. Hold him firmly by the ankles, but don’t dangle him upside down. If you have not already done so, tie (clamp) the umbilical cord with two ties (preferably sterile—dipped in boiling water, for example), one at 6 in (15 cm) and one at 8 in (20 cm) from the child. Use cord that won’t slip a knot, shoelace material, or cotton tape. Cut carefully between the ties. Suction the baby’s mouth and nose (newborns are nose breathers) again, and stimulate him by rubbing with a towel until he begins to cry. Gently wipe off all the residual slimy material. Wrap the child in a blanket and hand him to the mother to hold. The mother may begin to breast-feed at this point.

The long end of the umbilical cord, which is still attached to the placenta that is attached to the inside wall of the uterus, will be hanging from the mother’s vagina. The placenta will deliver spontaneously, so do not pull on the umbilical cord. Do not massage the mother’s abdomen (uterus) until after the placenta is delivered. Place the placenta in a plastic bag and bring it to civilization for inspection. After the placenta is delivered, gently massage the mother’s abdomen for 30 minutes. This stimulates the uterus to contract and helps control bleeding. It will feel like a firm, rounded, grapefruit-sized mass in the middle of the lower abdomen just above the pubic bone. If bleeding starts again, massage more vigorously. You may have to repeat this a few times during the hours immediately following childbirth. It may be uncomfortable for the mother.

If bleeding seems profuse after the placenta is delivered, or if the placenta does not spontaneously deliver after 60 minutes, be prepared to treat for shock (see page 60).

If the vagina is torn, apply pressure with a sterile compress. After the bleeding slows, the vaginal area can be gently washed, with the mother on her back, so that rinse water flows away from the vagina toward the anus. Take care to keep any contaminating material or solutions out of the vagina. Lay a sterile compress or clean sanitary napkin over the vagina.

After a wilderness birth, administer an antibiotic (cephalexin, amoxicillin-clavulanate, or erythromycin) to the mother for 48 hours.

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