Survival Labor and Delivery, by John O. MD

Tuesday, Jul 10, 2007

The return of home delivery is a fact that most of the survivalist community needs to face, and is a topic I have seen relatively little written about. My own experience derives from 10 years experience as an Emergency Physician, delivering 3-4 infants a year in situations either where the woman has had no prenatal care whatsoever and arrives in our emergency room (ER) [in] crowning [condition]; or as a private patient upstairs who progresses so quickly that her private obstetrician (OB) can't make it to the hospital in time. This has skewed my experience toward “normal” presentations where the baby is in normal position (not breach), as those tend to progress slowly enough for the OB to get involved. That said, “normal” delivery with minor complications is the area where preparation can make a big difference. Before we start, I believe that as a community, we need to accept the fact that the rates of death for both mother and infant are going to rise significantly if TSHTF. No amount of preparation is going to allow someone to do a c-section on their kitchen table and even breach presentations may be more than a layman can expect to handle.
The services of a good midwife would be invaluable, and the addition of a text such as “Heart and Hands” by Elizabeth Davis may be a wise addition to your stores as a second best choice. My goal is to help you keep a “good” delivery from going bad and preventing complications. It should go without saying that this information is for educational/survival purposes only, and I not suggesting a specific course of care. Fortunately, nature really does run its course in most cases, and there is a reason why one of the first procedures you get to do in Med. School is to “play catch” in labor and deliver (L&D) because there is so little to screw up under normal conditions.
Labor can be divided into a first phase -- a time when the cervix is thinning out and slowly dilating to from a canal roughly the diameter of pencil up to about 10 cm—and a second phase when the pushing begins and the mother actually pushes the baby out. The 1st phase is often divided into an early period, where the cervix is less than 4cm and contractions are relatively mild and spaced farther apart (7-8 min), as well as a late phase when the contractions are much harder and closer together. The early phase is pretty variable in length varying from a maybe two hours in multiparous women (lots of previous pregnancies) to as much as 24 hours in prima gravis (1st pregnancy). Late 1st phase tend to be more regular with the average woman dilating about 1 cm. per hour. Woman will usually want to get up out of bed, especially in the late phase. Encourage it, laying in a bed during labor is a bad habit that is really only necessary in hospitals due to the use of epidurals and intravenous (IV) narcotics. I have found that squatting really does help speed the progression as well as minimizing labor pains. You will note in the hospital that a woman's cervix is checked frequently, I would urge strongly against this practice at home. In the hospital setting, a woman who is not progressing may get a dosage of the labor hormone pitocin [("pit")], or may even go for a caesarian sections, neither of which you will be doing at home. In addition, they have a limitless supply of sterile gloves, so the risk of introducing infection into the birth canal is relatively low. In home deliveries where labor without pitocin tends to take longer, infection prevention is crucial. You will have a pretty good idea how things are progressing just by monitoring the frequency of contractions and the look on her face. Speaking of infection, now would be good time to discuss an infection called Group B strep. Group B Strep (GBS) is a bacteria that roughly 30% of woman carry in their birth canal. While passing through the canal about 60% of children will be colonized if the mom has it. Even in modern medicine, about 1 in 200 will develop severe complications such as pneumonia, meningitis or sepsis (blood poisoning). All woman are currently screened at about 37 weeks and treated with IV antibiotics prior to beginning labor. This has been shown pretty conclusively to reduce the amount of GBS in the canal, lowering the rates of colonization of babies. In addition, penicillin based antibiotics readily cross the placenta and afford the baby some protection even if he is colonized.
Since I don't imagine people will be getting screened for GBS in the future, I would recommend every woman start taking an antibiotic about 10-14 days prior to their due date. While IV antibiotics are currently recommended, oral where used pretty regularly until about 10 years ago. Ampicillin is probably best, any -cillin or cephalosporin (things that start with “ceph or cef” in their name such as Cephalexin (Keflex), Ceftin, Cefazolin, Rocephin, etc.) are good. -Mycin based antibiotics could probably be used in a pinch or for seriously penicillin allergic patients. DO NOT use -cyclines or anything with -floxin in the generic name as these are both toxic to young children.
After getting through the 1st phase, the woman will begin to feel the need to push or the sensation of needing to have a bowel movement from the baby's head pushing on the pelvis and bowel. I generally recommend getting back in bed at this point, though some midwives keep them up even now. At this point clean the entire pelvic area with either betadine, iodine, or high proof alcohol, including maybe 1/2-1 in. inside the vagina itself. Begin working on stretching the back wall of the vagina (also known to some as the taint) using KY jelly or oil. Take the area at about 7o'clock and 5'oclock as looking at the vagina between your thumbs and forefingers and stretch sideways and outward. Start gently but work up in force. Trust me, no amount of force you apply is going to equal the stretching from the head real soon. As the child begins to crown, assuming that you have clean or sterile gloves, work your fingers up around the neck to make sure the cord isn't wrapped around it. If it is, you can usually pull on the stretchy cord while pushing the head slightly back in to pull the cord up over the face and head to untangle it. If you don't have really clean hands, wait a little longer until the face is partly out, though this tends to increase the tension on the cord making it harder to get off. Unreduced nucal cords [umbilical cords wrapped around the neck] are a major source of death or brain damage in “normal” deliveries due to strangulation as they tighten, so don't forget to check. Finally the face will be out and the child will normally stick at the shoulders, as this is the widest point on the child. Take this time to suction the babies nose and mouth pretty thoroughly. I would highly recommend getting several blue bulb syringes over the counter now for just such a situation. If you note a greenish slime (meconium) on the baby or in his mouth, this means he has had a bowel movement due to the stress of labor, or because of the above mentioned nucal cord. It is very important to get this out of the throat and nose now, because once he comes out the rest of the way and takes his first breath, he will suck this junk down into his lungs. A small amount of previously boiled water may help to make it runnier and easier to suction. The meconium itself is sterile, and is no cause for alarm, other than the risk of aspirating it. Passing the shoulder is a little more difficult. Most of the time one can reach up and grasp the shoulders, pushing the trunk down to deliver the front shoulder, then up to deliver the back one. Sometimes an assistant can put pressure over the bladder while flexing the leg up into the air to help push the shoulder down to get it to pass under the pelvic bone. One can do a Google search on "McRoberts maneuver" for a more detailed and complex version. Do not tug down on the head itself, as it can tear the nerves going into the arm from the neck. Also, do not push down on the top of the uterus, as this can cause some serious problems as well. In a truly desperate situation, the baby's collar bone can be broken to cause the shoulder to collapse some. While it sounds horrible, they heal pretty readily, and is something I've had to do even in the hospital setting once or twice. One puts one palm over the breast bone of the baby and the other behind the shoulder of the collar bone to break, then one presses with both thumbs in the center of the clavicle with a force slightly greater than breaking a turkey wishbone. You will definitely feel the “pop”. It is important to note that after the first shoulder delivers, the baby pretty much wants to pop right out. Try to get the mom to breathe through her nose and stop pushing while you apply pressure back in, so that the baby slides out in a controlled fashion. Letting it slide out uncontrolled will greatly increase the risk of a tear to the mom.
After the baby passes, Lower him below the level of the birth canal to help his blood flow out of the placenta and back into his body. After about maybe 30 seconds clamp the cord with whatever you have (boiled clothespins?). Clamp above and below where you intend to cut, which is usually about 1-1/2 inches from the baby's belly. Cut with a sterilized blade, as this is a major source of infection in the third world. Keep the clamp on the baby for about a day or two until the vessels scar down. Clean baby with a dry cloth to remove all the slime and immediately wrap in a warm blanket, as babies have a hard time controlling their body temps initially. You can stimulate the baby if he isn't crying by rubbing his breast bone with your knuckle using moderate force or by a light pinch. Try to get the baby to breast-feed right away, as it will help the mom's uterus collapse down and minimize bleeding. Massage her belly, pressing down on her uterus at a moderate force (enough to be somewhat uncomfortable). After the uterus has contracted the placenta will separate from the uterus. After separation, apply gentle traction to end of the placenta to get it to pass, though too much force can cause the placenta to tear and leave behind a piece that can be a source for later infection. [The Memsahib Adds: Traction too early, when the placenta is still attached can cause an internal hemorrhage and the mother to bleed to death!] Ibuprofen works well to help with postpartum soreness and residual contraction pain. Four 200mg tablets will usually do the trick. As an aside, try to avoid aspirin products because they thin the blood and will increase bleeding, especially if taken before the actual delivery. I have not addressed breach births, as whole chapters can be written on the topic. One relatively simple procedure that can be tried before labor starts if the head is felt to be up instead of down is called external cephalic version. There are some risks, such as an early water breakage, but is probably better to try to fix the problem early, rather than waiting until the baby has entered the birth canal. Hopes this helps, hope no one ever has to use it. Once again, this for informational/education purposes, and is not a substitute for proper medical care.


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