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Help the mother give birth

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HealthWiki > A Book for Midwives > Chapter 12: Pushing: stage 2 of labor > Help the mother give birth

Help prevent tears in the vaginal opening

The birth of the baby’s head may tear the mother’s vaginal opening.

Some midwives do not touch the vagina or baby at all during the birth. This is a good practice because interference can lead to infection, injury, or bleeding. But you may be able to prevent tears by supporting the vagina during the birth.

Often tears happen whether you try to prevent them or not.

Cutting a circumcision scar

In some communities, circumcision of girls (also called female genital cutting) is common. Female genital cutting (FGC) causes scars that may not stretch enough to let the baby out.

If the mother has been circumcised, you may need to cut open the scar of the circumcision before the baby’s head starts to crown. See more explanation about female genital cutting, and how to cut a circumcision scar.

You should not cut the opening of the vagina to let the baby out, except in an emergency or for a woman who has had FGC. Learn how to cut the opening of the vagina in an emergency.

Support the vaginal opening

These instructions can be used when the baby is in the most common position — facing the mother's back.

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  1. Wash your hands well and put on sterile gloves.
  2. Press one hand firmly on the perineum (the skin between the opening of the vagina and the anus). This hand will keep the baby’s chin close to his chest — making it easier for his head to come out. Use a piece of cloth or gauze to cover the anus.
  3. Use your other hand to gently move the top of the baby’s head down towards the mother’s bottom and out of the vagina.

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Use very warm cloths

Warm cloths around the vaginal opening help bring blood to the skin, making it more soft and stretchy:

  1. Boil a pot of water for 20 minutes to kill any germs. If possible, add a little disinfectant (like iodine or betadine). If you do not have a disinfectant, add a little salt to the water. Let the water cool a little before you use it. The water should be hot, but not hot enough to burn the mother.
  2. Dip a clean cloth in the water and squeeze it out.
  3. Press the cloth gently on the mother's genitals.

Slow the birth of the head

If the head is born slowly, the mother’s vagina has more time to stretch and may be less likely to tear. To slow the birth of the head, help the mother stop pushing, or give very small pushes, right before the baby’s head crowns.

a woman on her hands and knees, with baby's head visible in the vagina.
This mother should stop pushing. The baby's head is about to crown.
To help the mother stop pushing

The need to push can be very strong, so it is not always easy for the mother to stop. It is best to warn the mother that you are going to ask her to stop pushing before the baby crowns.

When you want the mother to stop pushing, tell her to blow hard and fast. (It is difficult to blow and push at the same time.) Or, if the baby’s head is not coming out and the mother can control her pushing, ask her to give very small pushes in between contractions — and then stop and blow during the contractions. This gives her skin time to stretch. Each small push should move the head no more than 1 centimeter farther out of the mother. A centimeter is this long, roughly the width of your smallest finger.
arrows showing a 1-centimeter space.

After the widest part of the head comes out, the rest of the head may come out without any pushing at all.

a midwife speaking to a mother while the baby's head is coming out.
Do not push! Blow! Blow! Blow! Blow!
Whoo! Whoo!
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Okay. Give a small push. Good!
Gently! Good.
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Enough — stop pushing and blow! Keep blowing.
In a minute give another gentle push... good.
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Is the contraction over? Take a rest. The head is almost born.
Whooo. Here is another one.
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Gently! Yes! It's coming — stop pushing!
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And here is the head! How beautiful!

WARNING!   Do not slow the birth of the head if:

In any of these cases, the baby must be born as quickly as possible.

If necessary, clear the baby's nose and mouth

When the head is born, and before the rest of the body comes out, you may need to help the baby breathe by clearing her mouth and nose. If the baby has some mucus or water in her nose or mouth, you can wipe it gently with a clean cloth wrapped around your finger. You do not need to suction.

A baby who might have breathed in some waters should be held with her head a little lower than the rest of her body, so fluid can drain out.

If the waters were yellow or green it means the baby may have meconium (stool) in her mouth and nose and risks breathing it into her lungs. You may need to be ready to clean out the baby’s mouth with a suction trap or a bulb syringe (sometimes called an ear syringe).

But remember that most babies do not need to be suctioned at all. Suctioning can cause the baby to have trouble breathing. Only suction if there is meconium.

Check for a cord around the baby's neck

a gloved hand lifting the cord off the the baby's neck after the head is born.

If there is a rest between the birth of the head and the birth of the shoulders, feel for the cord around the baby’s neck.

If the cord is wrapped loosely around the neck, loosen it so it can slip over the baby’s head or shoulders.

If the cord is very tight, or if it is wrapped around the neck more than once, try to loosen it and slip it over the head.

If you cannot loosen the cord, you may need to deliver the baby around the cord. As the head begins to deliver, keep the head close against the mother's thigh, and let the baby's body somersault out around the head. Once the baby is out, you can unwind the tight cord and let the trapped blood flow back into the baby.

It is very rare that a tight cord would prevent a baby from being born. If the baby has already been born up to the shoulders, the cord should be long enough for the body to be born too. If a baby's head is born and the body is not coming, most likely the shoulders are stuck.

If you cut the cord before the birth of the baby, the baby cannot get any oxygen until he begins to breathe, which makes an emergency. In the very rare case you must cut a cord before the birth of the baby, use medical hemostats and blunt-tipped scissors for clamping and cutting the cord in this situation. If you do not have them, use clean string and a new or sterilized razor. Be very careful not to cut the mother or the baby’s neck.

cutting the cord wrapped around the baby's neck.
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medical hemostats blunt-tipped scissors

WARNING!   If you cut the cord before the birth of the baby, the mother must push hard and get the baby out fast. Without the cord, the baby cannot get any oxygen until he begins to breathe.

Deliver the baby's shoulders

After the baby’s head is born and he turns to face the mother’s leg, wait for the next contraction. Ask the mother to give a gentle push as soon as she feels the contraction. Usually, the baby’s shoulders will slip right out.

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Baby gets stuck at the shoulders

Sometimes a baby gets stuck at the shoulders. One of the shoulders is stuck behind the mother’s pubic bone.

Before this happens, there are usually warning signs. His head may take lots of hard pushing to be born, instead of coming out smoothly after it crowns. The chin may not quite come out. Sometimes it looks as if the baby’s head is being pulled back into the mother, like a turtle pulling its head into its shell.

Sometimes when the head is born, it will be pulled tight against the mother’s genitals. The baby may not turn to face the mother’s thigh. Even hard pushing will not bring the shoulders out.

A baby who is stuck at the shoulders is in danger! The pressure of the mother’s vagina on the baby’s body forces blood into the baby’s head. The head turns blue, and then purple. After about 5 minutes, the blood vessels in the baby’s brain may begin to break and bleed from the pressure. This will cause brain damage. In time, the baby will die.

What to do

You may have to do things which cause pain to the mother but are necessary to save the baby’s life and prevent brain damage. You must work quickly. As you are working be sure to reassure the mother to help her stay relaxed.

Here are 4 methods for helping the shoulders come out. Try one method at a time, in the order listed here.

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  1. Try the hands-and-knees position.
    Put the mother in the hands-and-knees position.

    Cup your hands around the baby’s head and gently pull straight back while counting to 30. When you see the shoulder, pull up and deliver normally.

    If this does not work, try the next method.
  2. Try pressure above the pubic bone.
    Quickly bring the mother to the edge of the bed. If she is on the floor, put something under her hips to raise them off the ground. You will need some space for the baby’s head when you pull down.
    MW Ch12 Page 211-2.png

    Help the mother grab her knees and pull them back as far as she can. Have helpers hold her legs in this position.

    Ask a helper or any other person in the room to press hard just above the mother’s pubic bone — not on the mother’s belly. The helper should push down hard.

    Ask the mother to push as hard as she can.

    Cup your hands around the baby’s head (do not hold the baby’s neck) and gently pull straight back while counting to 30. When you see the shoulder appear, pull up gently on the head and deliver normally.

    If this does not work, try the next method.

  3. MW Ch12 Page 211-3.png
  4. Try pushing the baby’s shoulder from the inside. With the mother in the hands-and-knees position, put your gloved hand inside the vagina along the baby’s back. Put your fingers on the back of the shoulder that is nearest to the mother’s back.

    Push the shoulder forward until it moves to the side.

    Deliver the baby in the usual way, pulling back while counting to 30.

    If this does not work, try the next method.
  5. MW Ch12 Page 212-1.png

  6. Try pulling the baby's arm out of the vagina.
    Put your hand inside the vagina and up along the baby’s back.
    MW Ch12 Page 212-2.png

    Move your hand around the baby’s body, bend the baby’s arm, and grasp his hand. Pull the hand across the baby’s chest and out of the birth opening. This is very difficult to do. Be careful not to push the collarbone inward as this can cause injury and bleeding inside the baby.

    MW Ch12 Page 212-3.png

    The baby can now be born easily. Grasp the baby by the body (not the arm) and help him come out.

If none of these methods work, it is better to break the baby’s collarbone to help him out than to let him die. Reach in with your finger, hook the baby’s collarbone, pull up toward the baby’s head, and break it. You will need to use a lot of pressure.

WARNING!    Never jerk on the baby’s neck, or bend it too far. You could tear the baby’s nerves. Babies who get stuck usually have a hard time breathing when they come out. Be ready to help the baby breathe.

Deliver the baby's body and give the baby to the mother

After the shoulders are born, the rest of the body usually slides out easily. Remember that new babies are wet and slippery. Be careful not to drop the baby!

Dry the baby immediately with a clean cloth and if everything seems OK, put the baby on her mother’s belly, skin to skin. This is the best way to keep the baby warm. You do not have to wait until the placenta comes out or the cord is cut. Cover the baby with a clean blanket, and make sure the baby's head is covered with the blanket or a hat.

Babies should breastfeed soon after birth. A baby may show she is ready to feed by moving her mouth or making smacking noises. Help the mother begin feeding.

After delivery, a baby should stay skin to skin with her mother for at least an hour without being separated.

Stool in the amniotic waters (green or yellow)

If the waters were green or yellow, it means the baby passed stool in the womb. If stool gets into the baby’s lungs it can damage them. You can tell if the baby is in danger of this happening by the baby’s condition when he is born.

If the baby is in good condition you can give him directly to his mother’s arms:

  • strong (good muscle tone, not floppy)
  • breathing or crying
  • heartbeat over 100 beats per minute

If the baby needs help, you must suction his mouth and throat before he breathes:

  • weak and floppy, like a doll
  • not breathing
  • heartbeat less than 100 beats per minute

The best way to suction the baby is to use a suction trap, but you can also use a bulb syringe. Whatever you use must be sterile (see how to sterilize tools).

To make a suction trap

You need a small jar, a stopper that fits snugly into the top of the jar, and some very thin, soft tubing that can be cleaned easily. Sterilize the tubing before and after you use it.

Make 2 holes in the stopper.

The holes should be just big enough to push the tubing through.
illustration of a suction trap.
Push one tube through the hole until it is just below the stopper. Push the second tube through until it almost touches the bottom of the jar.

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To use a suction trap

First put the tube that goes to the bottom of the jar in the baby’s mouth. It should go no more than 10 centimeters (4 inches) down the baby’s throat.

Suck on the other tube while you wiggle the first tube around in the baby’s mouth. The fluid in the baby’s mouth or nose will go into the jar but not into your mouth. After you clean the baby’s mouth, clean the baby’s nose in the same way.

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To use a bulb syringe

Sterilize a bulb syringe before you use it. Suction the mouth and throat until they are clear of mucus. Then suction the nose. (Practice using the syringe to suck up water before you use it at a birth.)

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Release the syringe as you wiggle it around.
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Squeeze the syringe. Gently put the syringe in the baby’s throat. The bulb will suck up mucus. (Do not squeeze the syringe while it is in the mouth.) Squeeze out the mucus.

Cut the cord when it turns white and stops pulsing

a fat, dark, pulsing cord.
a thin, white cord.
Wait! OK to cut.
Most of the time, there is no need to cut the cord right away. Leaving the cord attached will help the baby to have enough iron in his blood. It will also keep the baby on his mother’s belly where he belongs. When the baby is just born, the cord is fat and blue. If you put your finger on it, you will feel it pulsing. This means the baby is still getting oxygen from his mother. When the placenta separates from the wall of the womb, the cord will get thin and white and stop pulsing. Now the cord can be cut, usually after about 3 minutes.(Some people wait until the placenta is born before cutting the cord. This is a healthy custom.)
To tie a square knot
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the 1st loop of a square knot
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the 2nd loop of a square knot
Right over left, left over right, makes a square knot secure and tight.
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How to cut the cord

Use a sterile string or sterile clamp to tightly tie or clamp the cord about 2 finger widths from the baby’s belly. (The baby’s risk of getting tetanus is greater when the cord is cut far from his body.) Tie a square knot.

Put another sterile string or clamp a little farther up the cord.

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Cut the cord between the strings or clamps with a sterile knife, razor blade, or scissors. (Anything that is sharp enough to cut the cord will work, as long as it has been sterilized using one of the methods in this book.)

Leave the string or clamp on until the cord stump falls off — usually within the first week.

WARNING!   Do not put dirt or dung on the cord stump! Dirt and dung do not protect the stump — they cause serious infections. Protect the stump by keeping it clean and dry.

This page was updated:11 Sep 2019