U EMERGENCY CHILDBIRTH A REFERENCE GUIDE FOR STUDENTS OF THE MEDICAL SELF-HELP TRAINING COURSE LESSON NO. 11 ACKNOWLEDGMENT We wish to acknowledge with grateful appreciation the many servicesprovided by the American Medical Association, through the Committee onDisaster Medical Care, Council on National Security, Board of Trusteesand staff, in the preparation of this handbook. From the inception of studies to determine emergency health techniquesand procedures, the Association gave valuable assistance and support. The Committee on Disaster Medical Care of the Council on NationalSecurity, AMA, reviewed the material in its various stages ofproduction, and made significant contributions to the content of thehandbook. A joint publication of the U. S. DEPARTMENT OF DEFENSE Office of Civil Defense and the U. S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service Health Services and Mental Health Administration Division of Emergency Health Services 5600 Fishers Lane, Rockville, Maryland 20852 Reprinted December 1970 EMERGENCY CHILDBIRTH What To Do 1. Let nature be your best helper. Childbirth is a very natural act. 2. At first signs of labor assign the best qualified person to remain with mother. 3. Be calm; reassure mother. 4. Place mother and attendant in the most protected place in the shelter. 5. Keep children and others away. 6. Have hands as clean as possible. 7. Keep hands away from birth canal. 8. See that baby breathes well. 9. Place baby face down across mother's abdomen. 10. Keep baby warm. 11. Wrap afterbirth with baby. 12. Keep baby with mother constantly. 13. Make mother as comfortable as possible. 14. Identify baby. What Not To Do 1. DO NOT hurry. 2. DO NOT pull on baby, let baby be born naturally. 3. DO NOT pull on cord, let the placenta (afterbirth) come naturally. 4. DO NOT cut and tie the cord until baby _AND_ afterbirth have been delivered. 5. DO NOT give medication. DO NOT HURRY--LET NATURE TAKE HER COURSE. If it becomes necessary for families to take refuge in fallout sheltersthere will undoubtedly be a number of babies born under difficultconditions and without medical assistance. Every expectant mother and the members of her family should do all theycan to prepare for emergency births. They will need to know what to doand what to have ready. (See "Expectant Mother's Emergency Kit. ") SPECIAL SAFEGUARDS A pregnant woman should be especially careful to protect herself fromradiation exposure. She should have the most protected corner of theshelter and not be allowed to risk outside exposure. She should notlift heavy objects or push heavy furniture. If food shortages exist, she should be given some preference. Fear and possible exertion involved during an atomic attack willprobably increase the number of premature births and of miscarriages. PREPARATIONS Usually there is plenty of time after the beginning of first laborpains to get ready for the delivery. Signs of labor are low backache, bloody-tinged mucous strings passing from the birth canal, or a gush ofwater from the birth canal. The mother will need a clean surface to lie on. Her bed should be soarranged that the mattress is well protected by waterproof sheeting orpads made from several thicknesses of paper covered with cloth. Coverthese protective materials with a regular bedsheet. A warm bed should be made ready in advance for the baby. It may be aclothes basket, a box lined with a blanket, or a bureau drawer placedon firm chairs or on a table. If possible, warm the baby's blanket, shirt, and diapers with a hot water bottle. Warm bricks or a bag oftable salt that has been heated can be used if a hot water bottle isnot available. A knife, a pair of scissors, or a razor should be thoroughly cleansedand sterilized in preparation for cutting the umbilical cord. If thereis no way to boil water to sterilize them (the preferred method ofsterilization), sterilize them by submersion in 70 percent isopropylalcohol solution for at least 20 minutes or up to 3 hours, if possible. Sterile tapes for tying the umbilical cord will be needed. (Do notremove them from their sterile wrappings until you are ready to usethem. ) If no tapes are available, a clean shoestring or a strip ofsheeting (folded into a narrow tie) can be boiled and used wet as acord tie substitute. STAGES OF LABOR Labor is the term used to describe the process of childbirth. Itconsists of the contractions of the wall of the womb (uterus) whichforce the baby and, later, the afterbirth (placenta) into the outsideworld. Labor is divided into three stages. Its duration varies greatlyin different persons and under different circumstances. During the first and longest stage, the small opening at the lower endof the womb gradually stretches until it is large enough to let thebaby pass through. The contractions (tightening) of the uterus, whichbring about this stretching and move the baby along into the birthcanal, cause pains known as labor pains. These pains, usually beginning as an aching sensation in the small ofthe back, turn in a short time into regularly recurring cramplike painsin the lower abdomen. By placing your hand on the mother's abdomen justabove the navel, you can feel each tightening of the uterus as anincreasing firmness or hardness. It lasts for 30 to 60 seconds. Thepains disappear each time the uterus relaxes. At first these pains occur from 10 to 20 minutes apart and are not verysevere. They may even stop completely for a while and then start upagain. The mother should rest when she is tired but need not be lyingdown continuously. She may sleep between tightenings if she can. Shecan take a little water or perhaps tea during the entire labor process. She should urinate frequently during labor so the bladder will be asempty as possible at the time of birth. The skin in the vaginal area of the mother should be spongedoccasionally with soapy water. Special attention should be given tocleaning the inner sides of the thighs and the rectal area with heavylather. Soap or water should not be allowed to enter the vagina. A slight, watery, bloodstained discharge from the vagina normallyaccompanies labor pains or occurs before the pains begin. For first babies, this stage of labor may continue for as long as 18hours or more. For women who have had a previous baby, it may last only2 or 3 hours. The end of this first stage is usually signaled by the sudden pressingof a large gush of water (a pint or so), caused by the normal breakingof the bag of waters which surrounds the baby in the mother's womb. Forsome women, the bag of waters breaks before labor begins or perhaps asthe first sign of its beginning. This should not cause the mother orthose helping her any concerns. It usually does not seriously affectthe birth. Through this first stage of labor, the mother does not have to work tohelp the baby be born. She should not try to push the baby down, butshould try to relax her muscles. She can help do this by taking deepbreaths with her mouth open during each tightening. [Illustration: A. At full term, or after 40 weeks of pregnancy, thebaby is ready to be born. The cervix through which baby must leave theuterus is shown clearly here, still closed. The contractions of themuscles of the uterus will open the cervix, and force the baby downthrough the vagina, or birth canal, to the outside. ] [Illustration: B. At the end of the first stage of labor the cervix iscompletely open and the baby's head is beginning to come down throughthe vagina. Contractions begin in the lower back and later are felt inthe lower abdomen. At the time shown here contractions are probablycoming every 2 minutes, lasting 40-60 seconds and very strong. ] [Illustration: C. The first stage of labor usually lasts several hoursand is hard work. The mother needs to relax, rest, and be reassured. Give her water and fruit juices. In this picture the second stage oflabor is well along. It is shorter than the first stage and the motherwill now be pushing down with each contraction, helping to force thebaby into the world. ] [Illustration: D. The head of the baby has been partially born. Thisshows the usual position with the face down and the back of the headup. The bag of waters in which the baby is enclosed throughout thepregnancy may have broken at the beginning of labor, before or duringthe first stage. It may break now, or have to be torn with the fingers. ] [Illustration: E. Here you see the baby's head turned to the right asis usual. The shoulders are about to be born. The head must turn sothat the baby's body can fit into the birth canal and come through moreeasily. After the birth of the baby there will be further uterinecontractions and the placenta will be separated from the uterine walland expelled. ] CHANGE OF FEELING Gradually the time between the labour pains grows shorter and the painsincrease in severity until they are coming every 2 to 3 minutes. Itwill not be long now before the baby is born. At this stage the mother will notice a change. Instead of the tightnessin the lower abdomen and pain across the back, she will feel a bearingdown sensation almost as if she were having a bowel movement. Thismeans the baby is moving down. When this happens, she should lie down and get ready for the birth ofthe child. The tightening and bearing down feelings will come morefrequently and be harder. She will have an uncontrollable urge to push down, which she may do. But she should not work too hard at it because the baby will be broughtdown without her straining too hard. There will probably be more bloodshowing at this point. _The person attending the delivery should thoroughly scrub hands withsoap and water. Never touch the vagina or put fingers inside for anyreason. The mother also should keep her hands away from the vagina. _ As soon as a bulge begins to appear in the vaginal area and part of thebaby is visible, the mother should stop pushing down. She should try tobreathe like a panting dog with her mouth open in order not to push thebaby out too rapidly with consequent tearing of her tissue. She should keep her knees up and legs separated so that the personhelping her can get at the baby more easily. MOMENT OF BIRTH _The person helping the mother should always let the baby be born byitself. No attempt should be made to pull the baby out in any way. _ Usually the baby's head appears first, the top of the head presentingand the face downward. Infrequently the baby will be born in adifferent position, sometimes buttocks first, occasionally foot or armfirst. In these infrequent situations, patience without interference inthe birth process is most important. The natural process of delivery, although sometimes slower, will give the child and the mother the bestchance of a safe and successful birth. The baby does not need to be born in a hurry, but usually about aminute after the head appears the mother will have another bearing downfeeling and push the shoulders and the rest of the baby out. As the baby is being expelled, the person helping the mother shouldsupport the baby on her hands and arms so that the baby will avoidcontact with any blood or waste material on the bed. If there is still a membrane from the water sac over the baby's headand face at delivery, it should immediately be taken between thefingers and torn so that the water inside will run out and the baby canbreathe. If, as sometimes happens, the cord, which attaches the child from itsnavel to the placenta in the mother's womb, should be wrapped aroundthe baby's neck when his head and neck appear, try to slip it quicklyover his head so that he will not strangle. After the baby is born, wrap a fold of towel around his ankles toprevent slipping and hold him up by the heels with one hand, takingcare that the cord is slack. To get a good safe grip, insert one fingerbetween the baby's ankles. Do not swing or spank the baby. Hold himover the bed so that he cannot fall far if he should slip from yourgrasp. The baby's body will be very slippery. Place your other handunder the baby's forehead and bend its head back slightly so that thefluid and mucus can run out of its mouth. When the baby begins to cry, lay him on his side on the bed close enough to the mother to keep thecord slack. The baby will usually cry within the first minute. If he does not cryor breathe within 2 or 3 minutes, use mouth-to-mouth artificialrespiration. _Very little force should be used in blowing air into the baby'smouth_. A short puff of breath about every 5 seconds is enough. As soonas the baby starts to breathe or cry, mouth-to-mouth breathing shouldbe stopped. CUTTING THE CORD There should be no hurry to cut the cord. Take as much time asnecessary to prepare the ties and sharp instruments. You will need two pieces of sterile white cotton tape or two pieces of1-inch-wide sterile gauze bandage about 9 inches long to use to tie thecord. (If you do not have sterile material for tying the cord but dohave facilities for boiling water, strips of sheeting--boiled for 15 to20 minutes to make them sterile--can be used. ) Tie the umbilical cordwith the sterile tape in two places, one about 4 inches from the babyand the other 2 inches farther along the cord toward the mother, makingtwo or more simple knots at each place. Cut the cord between these twoties with a clean sharp instrument such as a knife, razor blade, orscissors. A sterile dressing about 4 inches square should be placed over the cutend of the cord at the baby's navel and should be held in place bywrapping a "bellyband" or folded diaper around the baby. If a steriledressing is not available, no dressing or bellyband should be used. Regardless of whether a dressing is applied or not, no powder, solution, or disinfectant of any kind should be put on the cord ornavel. If the afterbirth has not yet been expelled, cover the end of theumbilical cord attached to it (and now protruding from the vagina) witha sterile dressing and tie it in place. [Illustration: Cut between the square knot by bringing the left tapeover right tape for first loop and right tape over left for secondloop. Tighten each loop firmly as tied. Use scissors or a razor bladeto cut cord. ] THIRD STAGE OF LABOR Usually a few minutes after the baby is born (although sometimes anhour or more will elapse) the mother will feel a brief return of thelabor pains which had ceased with the birth. These are due tocontractions of the uterus as it seeks to expel the afterbirth. _Do notpull on the cord to hurry this process_. Some bleeding is to be expected at this stage. If there is a lot ofbleeding before the afterbirth is expelled, the attendant should gentlymassage the mother's abdomen, just above the navel. This will help theuterus to tighten, help the afterbirth come out, and reduce bleeding. It may be desirable to put the baby almost immediately to the mother'sbreast for a minute or two on each side even though the mother willhave no milk as yet. This helps the uterus contract, and reduces thebleeding. Someone should stand by the mother and occasionally massage her abdomengently for about an hour after the afterbirth is expelled. After thatthe mother should feel the rounded surface of the uterus through theabdomen and squeeze firmly but gently with her fingers. The beddingshould be cleansed and the mother sponged. Washing and wiping of thevaginal area should always be done from the front to the back in orderto avoid contamination. A sanitary napkin should be applied. Keep the mother warm with blankets. She may have a slight chill. Giveher a warm (not hot) drink of sweetened tea, milk, or boullion. Wipeher hands and face with a damp towel. She may drop off to sleep. The mother's diet after delivery may include any available foods shewishes. She may eat or drink as soon as she wants to, and she should beencouraged to drink plenty of fluids, especially milk. Canned milk canbe used and made more palatable by diluting with equal parts of waterand adding sugar, eggs, chocolate, or other flavoring. For the first 24 or 48 hours after delivery, the mother will continueto have some cramping pains in the lower abdomen which may cause agreat deal of discomfort. Aspirin may help relieve these afterpains. She should empty her bladder every few hours for 2 days following thebirth. If her bowels do not move within 3 days after delivery sheshould be given an enema. MISCARRIAGE If a pregnant woman shows evidence of bleeding, she should restrict heractivities and rest in bed in an effort to prevent possible loss of thebaby. If a miscarriage does occur, keep the patient flat with the footof the bed elevated from 12 to 18 inches to retard vaginal bleeding. Keep her warm and quiet, and give her fluids. EXPECTANT MOTHER'S EMERGENCY CHILDBIRTH KIT The public health and civil defense agencies of one State have planneda 1 1/2-pound emergency childbirth kit made up of basic supplies thatcan be carried in a 1-yard-square receiving blanket. The kit consists of the following: One-yard square of outing flannel, hemmed (receiving blanket). Plastic (polyethylene flexible film) for outer wrapping of the kit if desired. (_Do not_ wrap the baby in this plastic film. ) One or two diapers. Four sanitary napkins (wrapped). Adhesive tape identification strips for mother and baby. Short pencil. Soap. Sterile package containing: Small pair of blunt-end scissors (cheapest scissors will do), or a safety razor blade with a guard on one side. Four pieces of white cotton tape, 1/2 inch wide and 9 inches long. [1] Four cotton balls. Roll of 3-inch gauze bandage. Six 4-inch squares of gauze. [1] Two or more safety pins. [1] You will actually use only two tapes for tying the umbilical cord. The two extras are included as a safeguard in case one or two shouldbe dropped or soiled. Extra 4-inch squares of gauze also are included. [Illustration: Emergency childbirth kit] Instructions such as those contained in this chapter also should beconsidered a part of the emergency childbirth kit. To make the kit ready to carry, lay the plastic (if used) out flat, andlay receiving blanket out flat on top of the plastic. Place thediapers, sterile package, soap, sanitary napkins, identification tapes, pencil and instructions in the center. Pull two opposite corners of thereceiving blanket and plastic together and tie. Do the same with theother opposite corners, pulling each side together well so that nothingwill fall out. Then tightly knot the loose ends together in the sameway, leaving an opening so that the kit can be slipped over the arm forcarrying the kit while leaving the hands free. Such an emergency delivery kit will weigh about 1 1/2 pounds. Thecontents suggested are basic essentials only, for extreme emergency. Much more could be added, but the extra weight might mean leavingbehind some other items needed for survival. Additional supplies couldbe stored in your home shelter to be ready in the event the birth takesplace there. In the case there is no need for an emergency delivery, either in the home, shelter or in some evacuation situation, thesupplies in the kit can be used in home care of the baby. IDENTIFICATION TAPES In emergency situations, identification will be particularly important, especially if the birth should take place in a group shelter ratherthan a family shelter, or in an evacuation situation. Two wide strips of adhesive tape will be needed--one long enough to goaround the mother's wrist, and the other long enough to go around thebaby's ankle. Information should be written on these strips as shownbelow. [Illustration: For mother--Write parents' names, blood types, andmother's Rh factor, street address, and whether it is a first or laterchild. ] [Illustration: For baby--Write date and hour of birth and parents'names and address. ]