In survival settings, the family medic has to deal with a variety of different problems. Unlike what you might see in the movies, the problem may not be orthopedic trauma or gunfights at the OK corral. There’s always the possibility that they might be pressed into service as… a midwife.
Last time, we discussed how to recognize signs of labor in the late stages of pregnancy. In part 2 of the series, we’ll discuss the interval between the beginning of labor up until the delivery of the baby.
STAGES OF LABOR
There are three stages of labor (four, if you add recovery). The first stage is the longest, often lasting 20 hours or more in a woman’s first pregnancy. It begins when your cervix starts to dilate and efface (discussed in part 1), 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.
FIRST STAGE (LATENT PHASE)
The latent phase is when labor begins. False labor has been ruled out and contractions are stronger, more regular, and greater in frequency. They may also last longer (60-90 seconds). The contractions cause your cervix to dilate and efface. In the latent phase, however, dilation to about 4 centimeters or so often progresses slowly.
During this time, the mother should be given as much freedom to walk, sit, practice breathing techniques, or do any 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, you should be able to place two (normal-sized) fingertips in the cervix on vaginal exam. You’ll feel something firm inside the cervix; this is the baby’s head. More than 95 percent of deliveries will be headfirst.
Although vaginal exams can give important information, they are invasive and shouldn’t be performed more often than, perhaps, every two hours to follow the progress of the labor.
FIRST STAGE (ACTIVE PHASE)
When the cervix reaches 5 centimeters or so of dilation, labor enters the active phase. Contractions get even stronger and are spaced closer together. 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 around this time.
Cervical dilation in active phase speeds up to about a centimeter an hour, although it may go even faster in women who have had children. 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 well 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 to deliver than those who have had children. Those who have 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 one side with a leg raised, or even hands and knees. The body should “curl into” the push as much as possible, almost exactly like having 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 over time 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.
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 large jagged tear will occur that could damage the anal sphincter muscle or the 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 (with the clamps two inches or so apart) 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 and clear breathing passages.
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.
In the next part of this series, we’ll talk about the delivery of babies not in the headfirst (cephalic) position and what to do with twins or other multiples. We’ll also discuss the third stage of labor: the delivery of the placenta and after-delivery (called “postpartum”) care.
via doomandbloom
