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Nursing -Obstetrics and Gynecology
Guest Post By Dr. Bones
In our last two articles, we discussed how (and why) to prevent pregnancy in a long-term survival situation, as well as how to monitor a pregnancy for complications throughout the entire nine months. Now it’s time to discuss the actual physical process of delivery and how you, as medic, can help deliver a healthy baby.
l begin to “drop”, assuming a position deep in the pelvis. The patient’s abdomen may look different, or the top of the uterus (the “fundus”) may appear lower. As the neck of the uterus (the cervix) relaxes, the patient may notice a mucus-like discharge, sometimes with a bloody component. This is referred to as the “bloody show” and is usually a sign that things will be happening soon.
Examining a Pregnant PatientIf you examine your patient vaginally by gently inserting two fingers of a gloved hand, you’ll notice the cervix is firm like your nose when it is not ripe and soft like your lips when the due date is approaching. This softening of the cervix is called “effacement”. As time goes on, the sides of the cervix will thin out, until they are as thin as paper.
Dilation of the cervical opening will be slow at first, and speed up once you reach about 3-4 cm. At this level of dilation, you will be able to place two (normal-sized) fingertips in the cervix and feel something firm; this is the baby’s head.
Contractions will start becoming more frequent. To identify a contraction, feel the skin on the soft area of your cheek, and then touch your forehead. A contraction will feel like your forehead. False labor, or Braxton-Hicks contractions, will be irregular and will abate with bed rest, especially on the left side, and hydration. If contractions are coming faster and more furious even with bed rest and hydration, it may just be time to have a baby! A gush of watery fluid from the vagina will often signify “breaking the water”, and is also a sign of impending labor and delivery. The timing will be highly variable.
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 a collapse situation. If there is no chance of accessing modern medical care, it will be up to you to perform the delivery.
To get ready for delivery, wash your hands and then put gloves on. Then, set up clean sheets so that there will be the least contamination possible. Tuck a sheet under the mother’s buttocks and spread it on your lap so that the baby, which comes out very slippery, will land onto the sheet instead of landing on 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. Newborns are also susceptible to infection, so avoid touching anything but mother and baby if you can.
Baby DeliveryAs 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. It will help the process along.
To make space, place two gloved fingers in 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.
With each contraction, the baby’s head will come out a little more. Don’t be concerned if it goes back in a little after the contraction. It will make steady progress 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 vagina to make room for the baby to be delivered. This is called an “episiotomy”. I discourage this if at all possible, as the cut has to be sutured afterward. I always make this decision as the head is crowning.
As the baby’s head emerges, it will usually face straight down or up, and then turn to the side. The cord might appear to be 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 have to doubly clamp it and cut between. This will release the tension.
Next, gently hold each side of the baby’s head and apply gentle traction straight down. This will help the top shoulder out of the birth canal. Occasionally, steady gentle pressure on the top of the uterus during a contraction may be required if the mother is exhausted. Once the shoulders are out, the baby will deliver with one last push. The new mother can now rest.
Put the baby immediately on the mother’s belly and clean out its nose and mouth with a bulb syringe. It will usually begin crying, which is a good sign that it is a vigorous infant. Spanking the baby’s bottom to get it to cry is rarely needed, and is more of a cliché than anything else. A better way to stimulate a baby to cry is to rub the baby’s back.
Dry the baby and wrap it up in a small towel or blanket. Clamp the cord twice (2 inches apart) with Kelly or Umbilical clamps, and cut in between with a scissors. Delivery kits are available online with everything you need, including drapes, clamps, bulb syringes, etc.
Once the baby has delivered, it’s the placenta’s turn. Be patient: In most cases, the placenta will deliver in a few minutes. Pulling on the umbilical cord to force the placenta out is usually a bad idea. Breaking the cord due to excessive traction will require your placing your hand deep in the uterus to extract it, which is traumatic and can introduce infection. You can ask the mother to give a push when it’s clear the placenta is almost out. If traction is necessary for some reason, place your fingers above the pubic bone and press as you apply mild traction. This will prevent the uterus being turned inside out (a potentially life-threatening situation) if the placenta is stubborn. A moderate amount of bleeding is not unusual afterwards.
Once the placenta is out, examine it. The “fetal” surface is grey and shiny; turn it inside out and you will see the “maternal” surface, which look like a rough version of liver. The fetal surface is separated into compartments called “cotyledons”. If a portion of the placenta remains inside, you may have to extract it manually. The maternal and fetal surfaces, respectively, are shown in the images below:
Manual Extraction (very uncomfortable)
The uterus (the top of which is now around the level of the belly button) contracts to control bleeding naturally. In a long labor, the uterus may be as tired as the mother after delivery, and may be slow to contract. As a result, this may cause excessive bleeding. Gentle massage of the top of the uterus (known as the “fundus”) will get it firm again and thus limit blood loss. You may have to do this from time to time during the first 24 hours or so after delivery.
Place the baby on the mother’s breast soon after delivery. This will begin the secretion of “colostrum”, a clear yellow liquid rich in substances that will increase the baby’s resistance to infection. Suckling also causes the uterus to contract; this is also a factor in decreasing blood loss. Monitor the mother closely for excessive bleeding over the next few days. In normal situations, the bleeding will become more and more watery as time progresses. This is normal. Also, keep an eye out for evidence of fever or other issues.
Human pregnancy and delivery is a natural process and, usually, proceeds in an uncomplicated manner. Learning to help the process along and identifying problems will give you the best chance of bringing a healthy baby (from a healthy mother) into the world. Even in a survival situation, seek out experienced professionals that can help.