Labour and birth

 

Birth is natural and not usually dangerous but in a remote clinic you need to be ready in case something goes wrong

  • Always call for help — get midwife/doctor/obstetrician on speaker phone, if none locally
  • Find support people, if possible female ATSIHP or older women familiar with birthing
  • Reassure woman and explain what is happening. Have someone stay with her for support
  • Women who present unexpectedly in labour may 
    • Have had little or no antenatal care
    • Be more likely to be in preterm labor
    • Have declined transfer to a regional centre to wait for birth 

Labour

  • Labour pains are caused by contractions (tightening of uterus)
    • Between contractions uterus is relaxed
    • During contractions the uterus tightens — put your hand on woman’s abdomen to feel this happening
    • Each contraction pushes baby down on cervix and it opens a little more
  • Labour has started when there are regular, painful contractions — usually lasting 1 minute, occuring every 2–5 minutes
  • Membranes ruptured (waters have broken) when liquor (clear fluid) loss from vagina — doesn’t always mean birth will happen soon
  • Check colour of liquor (waters). Can be
    • Clear or pink — normal
    • Bloody — mixed with mucus (‘show’) — normal unless ‘frank ’ blood loss
    • Greenish/brown — meconium (baby poo) stained — baby may be distressed
  • Baby is coming when uncontrollable urge to push, grunting, wants to go to toilet to pass faeces, perineum or anus bulging AND/OR part of baby seen when labia parted, usually the head

First stage of labour

From start of labour until cervix fully dilated​

If woman arrives pushing and birth about to happen — see Getting ready to birth baby straight away

Check as much as you have skills and time to do

Ask

Ask woman, check notes and have helper phone hospital or other clinics for relevant information

  • Is there more than 1 baby
  • Is baby moving
  • Have movements gotten less over the last 24 hours
  • When labour (pains) started

What is happening now

  • Contractions
    • How often, how long — ask woman to tell you each time one starts
    • Time over 10 minutes
  • Membranes intact or ruptured
    • If fluid loss — when did it start and how much
    • Colour, smell, blood or mucus

Obstetric history

  • When is baby due
  • Antenatal care — problems or infections during pregnancy, medical or obstetric, eg positive GBS, untreated STI, diabetes, anaemia, UTIs
    • Obstetric ultrasound report — number of babies, position of placenta
    • Blood group
    • Latest test results
  • Number of previous pregnancies, number of live births, types of birth, multiple births
  • Problems during or after past births — high BP, pre-eclampsia, postpartum haemorrhage (bleeding after birth)

Medical history

  • Medicines, allergies, substance use
  • Bleeding disorders, diabetes, heart disease, kidney disease, high BP

Check

Do not do vaginal exam unless you are a midwife and have spoken to the on-call obstetrics team

Table 3.1   Timing of required checks

Do

  • Medical consult to talk about
    • Stopping labour
    • Sending to hospital
    • Pain relief — consider natural methods (breathing, relaxation, massage, heat) AND/OR medicines (nitrous oxide, opioids)
    • Antibiotics if unknown or positive GBS
    • Oxytocin for delivery of placenta and if bleeding after birth
  • Put in IV cannula — largest possible, insert 2 if time
  • If woman less than 37 weeks pregnant — help to mature baby's lungs by giving
    • Betamethasone ​IM — 11.4mg — 2 doses 24 hours apart
    • OR Dexamethasone IM — 6mg — 4 doses 12 hours apart
  • Make sure woman has emptied her bladder
  • Put clean pad between woman's legs and monitor loss
    • Small amount of blood and mucus ('show') is normal
    • If more than 50ml vaginal bleeding — see Bleeding in pregnancy — 1 soaked pad is equal to about 100ml blood loss
    • If meconium-stained liquor (green or brown vaginal fluid loss)  — medical consult
  • Let woman be in any position that makes her comfortable
    • Upright positions help labour/birth more than lying on back — Figure 3.1 for examples
    • If woman wants to lie down — encourage her to use wedge to tilt her to left side

Figure 3.1   

9 upright birthing positions — text description

  • On knees and elbows with head on pillow
  • On hands and knees
  • On knees with forearms resting on seat of chair
  • Squatting
  • Standing with head resting on arms against wall
  • Partial squat, supported from behind by helper
  • Standing with 1 foot on a stool and supported by helper
  • Standing bent forward, supported on outstretched arms with hands on bed
  • Standing bent forward, with forearms resting on back of chair

Second stage of labour​

From cervix fully dilated ​until birth of baby

Getting ready to birth baby

Do first

  • If not already in place, put in IV cannula — largest possible, insert 2 if time
  • Have helper collect birth and resuscitation equipment
  • If you have incubator — turn on, it needs time to heat up

Birthing baby

Have helper read out these instructions as you go along

  • Let woman birth baby in any position she wants but remind her upright positions are best — see Figure 3.1 for examples
  • If she chooses to lie down — encourage her to lie on her left side or use a wedge to tilt her to the left — lying flat on her back can be dangerous for mother and baby
  • Woman may pass faeces when straining to push. This is normal but can be embarrassing for her — gently remove, wiping away from baby

In normal birth

  • Baby will present (arrive) head first, usually with face toward mother’s back
  • Baby will be bluish colour at birth but becomes pink with first few breaths
  • Vaginal discharge will be clear or pink before birth, may be mucoid and/or bloody — should not be green or brownish

Do

  • Put clean sheet under woman
  • Use small combines to clean any ‘show’ or faeces from perineum — wipe from front to back
  • Open and set up birthing pack
    • Put on goggles and sterile gloves
  • Talk calmly — say things like “you are getting this baby out so well” , "everything’s stretching nicely", "that’s great, let the baby out slowly"

Birth of baby’s head and shoulders

Figure 3.2   

Figure 3.3   

Figure 3.4   

Figure 3.5   

Figure 3.6   

Figure 3.7   
  • Let woman push as she feels like it
  • When perineum stretched thin and labia wide apart (as head is being born) — ask woman to 'pant' or puff through contractions
    • Helps baby’s head to be born as slowly as possible
    • May help protect perineum from tearing
  • If membranes still intact ​and bulging — pop with gloved finger
  • Wait for next contraction — will take about 1 minute
    • As contraction ​starts baby’s head usually turns to face woman’s inner thigh — Figure 3.8, Figure 3.9

Figure 3.8   

Figure 3.9   
  • As woman pushes with contraction​​ shoulders should deliver
  • Shoulder under pubic bone comes out first

If shoulder doesn’t come out easily

Follow instructions for woman birthing on all fours or on back

  • If woman birthing on all fours
    • Wait for next contraction​ THEN holding baby’s head between palms of your hands gently lift up toward ceiling to release anterior (front) shoulder — Figure 3.10
    • When shoulder comes out from under pubic bone — ask woman to stop pushing
    • Gently guide baby downward toward bed/floor — Figure 3.11

Figure 3.10   

Figure 3.11   
  • If woman birthing on her back
    • Wait for next contraction THEN holding baby’s head between palms of your hands gently pull down toward bed to release anterior (front) shoulder — Figure 3.12
    • When shoulder comes out from under pubic bone — ask woman to stop pushing
    • Gently lift baby upward toward ceiling — Figure 3.13 Other shoulder should now appear

Figure 3.12   

Figure 3.13   

If shoulders still stuck — see Shoulder dystocia straight away. This is an emergency

Birth of body

  • Support head and shoulders while waiting for rest of body to slip out — may happen straight away or not until next contraction ​
  • Support baby as it births — it will be slippery, so use gentle but firm grip. Can use warm towel

After the birth

  • Make sure there is only 1 baby by feeling woman’s uterus — top of uterus should be no higher than umbilicus
    • If there is another baby — do not give oxytocin. See Twin birth
  • Give oxytocin IM — 10 international units in thigh
    • Watch for signs that placenta has separated from wall of uterus — trickle or gush of blood from vagina​ and lengthening of cord. Placenta should separate within a few minutes
    • If oxytocin is not used separation may take longer and there is an increased risk of postpartum haemorrhage (bleeding after birth)
  • Note time of birth

Immediate care of baby

  • Put baby skin-to-skin on mother’s chest/abdomen
    • If mother doesn't want baby on her — put baby between her legs, away from blood and mess
  • Dry baby very well and remove wet towel. Cover baby with warm dry towel making sure head is covered
  • Do 'rapid assessment' of baby’s condition
    • Breathing or crying
    • Muscle tone
    • Heart rate
  • If baby floppy and/or not breathing properly and/or heart rate less than 100 bpm — see Newborn resuscitation straight away
  • If baby breathing, good muscle tone, heart rate more than 100 bpm — leave in skin-to-skin contact with mother if possible
  • At 1 minute (after the birth) — check heart rate, RR, tone, response to stimulation, colour 

Have helper

  • Keep baby warm — see Keeping baby warm after birth
  • Watch baby closely over next few minutes for signs of respiratory distress
  • Encourage early breastfeeding — helps placenta separate from uterus and uterus to contract after placenta delivered

Clamp and cut cord

  • Some cultures like long cord left on baby — ask mother or support person
  • Wait at least 1 minute and until cord stops pulsating if possible
  • Put 2 metal clamps on cord 5cm apart, at least 10cm from baby’s abdomen — Figure 3.14
  • Cut cord between 2 clamps with sterile blunt-end scissors
    • Do not take clamps off after cutting

Figure 3.14   

Taking cord blood

Very important if woman RhD negative ​or blood group not known

  • If taking before placenta delivered
    • Unclamp metal cord clamp on placenta side
    • Let blood flow into clean kidney dish
    • Re-clamp
    • Use syringe to draw up 10ml of cord blood. Put into EDTA ​or plain specimen tube and label 'cord blood'
  • If taking after placenta delivered
    • Draw 10ml of blood from one placenta blood vessel with needle and syringe. Put into EDTA ​or plain specimen tube and label 'cord blood'

Third stage of labour​

From birth of baby until placenta delivered

If twins — only deliver placenta/s after birth of second baby

  • Watch blood loss ​closely — collect clots in kidney dish to measure later
    • Normal loss is less than 500ml but this can seem like a lot of blood
    • 1 soaked pad holds about 100ml
  • Deliver placenta
    • If oxytocin given — see Delivering placenta with controlled cord traction
    • If oxytocin not given — see Delivering placenta by maternal effort
  • Check for tears of birth canal

Delivering placenta with controlled cord traction

If traction applied to cord without uterus contracted — increased risk of uterine inversion

Do not

  • Do not do controlled cord traction if no oxytocin available or woman refuses it — see Delivering placenta by maternal effort

Do

  • Woman lying or half sitting on bed, with kidney dish between her legs
  • Check if oxytocin given — IM — 10 international units into thigh
  • Clamp and cut cord if not already done
  • Wait 5–10 minutes for signs that placenta has separated from wall of uterus and descended — trickle or gush of blood from vagina​, lengthening of cord
  • Clamp cord close to entrance of the vagina. Put fingers around clamp — Figure 3.15 or wrap cord around hand

Figure 3.15   
  • Put other hand above pubic bone with palm facing away from you. Use arch formed between thumb and first finger to apply counter traction. Push in and up to support uterus and hold it in place — Figure 3.15
    • If cord goes back in when you push on uterus — placenta hasn’t separated properly. Wait a few minutes before trying again
  • Apply gentle traction (pull) on cord — down toward bed
    • Do not apply cord traction without applying counter traction — Figure 3.15
    • Do not apply cord traction unless uterus well contracted
  • Stop traction (pulling) and medical consult if — any suggestion of cord tearing OR uterus relaxes — increased risk of uterine inversion
  • If no lengthening of cord
    • Wait a few minutes for placenta to separate then try again
  • If you feel movement — keep applying gentle traction (pull) to cord until you see placenta at vaginal opening
  • Hold placenta with both hands and slowly turn in one direction to peel membranes off wall of uterus
    • Keep turning slowly, while maintaining gentle traction, until whole placenta and membranes are out
    • Put placenta in kidney dish
  • Straight after placenta is delivered — check fundus (top of uterus) — usually found at level of umbilicus. Should be firm like a grapefruit
  • Check how much bleeding
  • Check placenta quickly to see if there are any pieces missing. Put aside to check again later
  • Record time placenta delivered

If placenta not delivered 

  • If placenta not delivered after following these steps — medical consult
  • If placenta still not delivered 30 minutes after birth — see Retained placenta

Delivering placenta by maternal effort

If no oxytocin available or woman refuses to have injection — do nothing and let placenta be delivered by mother’s effort only

Do not

  • Do not pull on cord at any stage — may cause more bleeding

Do

  • Watch for signs that placenta has separated from wall of uterus — trickle or gush of blood from vagina​ and lengthening of cord
  • Woman may feel a contraction or heaviness in pelvis. Usually has urge to push as placenta separates and drops down into lower part of uterus
    • Encourage woman to push when she gets the urge
    • May be easier in standing/squatting position or sitting on toilet/pan where gravity will help
  • As placenta delivers — collect in kidney dish
  • Straight after placenta delivered — check fundus (top of uterus) — usually found at level of umbilicus. Should be firm like a grapefruit
    • If soft — see Rubbing up a contraction
  • Check how much woman is bleeding
  • Record time placenta delivered
    • Check placenta ​quickly to see if there are any pieces missing. Put aside to check again later
  • If placenta not delivered 30 minutes after birth — medical consult and treat as retained placenta
  • Encourage breastfeeding as soon as possible after birth — releases oxytocin (natural hormone) that causes the uterus to contract

Fourth stage of labour

First hour after birth of placenta

  • Check that blood and swabs for all other routine tests have been collected
  • STI check
  • If mother comfortable — put baby on her chest, encourage skin-to-skin contact and breastfeeding. Offer help if needed
  • Offer woman something to eat and drink, shower and change of clothes
  • Encourage woman to pass urine - full bladder can stop uterus contracting and cause heavy bleeding
  • Make sure placenta checked and is complete
  • Medical consult
  • Make sure you know mother’s medical and obstetric history. Talk ​about
    • Labour, birth, condition of mother and baby
    • Problems with woman, baby, placenta
  • If needing to send to hospital — send placenta, birth documents, bloods, birth registration and family assistance forms with woman

Record in file notes

  • Date and time of birth of baby
  • Time of birth of placenta
  • How much blood woman lost — 1 soaked pad is equal to about 100ml
  • What you did, any problems you had, etc
  • Any medicines, immunisations given to mother and/or baby
  • Whether placenta and membranes complete or incomplete

Follow-up

  • Complete birth registration forms and see — Care of mother — first 24 hours after the birth
  • Don’t forget to celebrate and debrief
    • If challenged or distressed by anything you saw or did — talk with friends, colleagues and/or qualified counsellor, eg Bush Support Services on 1800 805 391

Rubbing up a contraction

Using hands to stimulate uterine muscles to contract after delivery of placenta

  • Relaxed uterus will bleed heavily
  • Only rub up a contraction if woman starts to bleed from relaxed uterus ​after delivery of placenta

Do

  • Gently feel fundus (top of uterus) after delivery of placenta and every 15 minutes for first hour — should be hard and size of a grapefruit
    • Warn woman that fundus (top of uterus) is very tender after birth but it is important to stop the bleeding
  • Have baby breastfeed if possible — helps uterus contract
    • Important that baby feeds within first hour after birth
    • Most babies do this themselves if held close to the breast
  • Encourage woman to empty bladder — full bladder stops uterus contracting
    • If unable to pass urine and blood loss heavy — put in indwelling urinary catheter
  • Using one hand, firmly rub fundus (top of uterus) — encourage deep breathing. Woman can use nitrous oxide for pain relief, if available
  • Keep doing this until uterus becomes firm
  • If uterus stays relaxed (feels spongy and bulky)