Hesperian Health Guides
Difficult Births
Contents
Cord comes out before the baby
Until birth, oxygen (and everything else a baby needs) comes through the umbilical cord. If the cord comes out before the baby’s head, the cord can be squeezed shut when the head comes down. The baby can get a brain injury or die from lack of oxygen.
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| cord showing at opening of vagina |
What to do:
If the baby is coming very fast, have the person in labor squat and push as hard as they can to get the baby out.
TRANSPORT!
If the baby is not coming quickly, put the person in labor in the knee-chest position, help them to stop pushing, and go quickly to a hospital. The baby needs to be born by operation.
If a baby is very big, the shoulders can sometimes get stuck after the head is born. The baby can die or be harmed if it is not born soon.
What to do:
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 DO NOT try to pull the baby out. This can hurt or kill the baby. |
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- Have the person in labor get on hands and knees, and push. The stuck shoulder will usually slip out and the baby can be born.
- If the hands-and-knees position does not work, move the person in labor’s bottom to the edge of the bed. Ask them to pull their knees back as far as they can while someone else pushes straight down just above the pubic bone. Then tell them to push as hard as they can during the next contraction.
- If the baby still does not come out, slide your hand along the baby’s neck until your fingers are touching the baby’s back. Push the baby’s upper shoulder forward at the same time the person in labor pushes with a contraction.
Twins
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If someone is pregnant with more than one baby, it is best to give birth in a health center or hospital. It is more likely that one baby will be in a wrong position, or that there will be heavy bleeding after the birth. But if you must help someone give birth to twins, here is what to do:
 Tie this end
of the cord too. |
What to do:
- Deliver the first baby just as you would any single baby.
- When you cut the first baby's cord, carefully tie the end that is coming out of the mother. If you do not, the second baby could die.
- Do not give oxytocin or other medicines to prevent heavy bleeding yet.
- Put the first baby to the breast to begin feeding. This will help the second baby be born.
- The second baby should be born within 15 to 20 minutes. Feel for its position. If the second baby is sideways, you can gently try to turn it. If it will not turn easily, you must go to the hospital.
TRANSPORT!
Cord around the baby's neck
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Sometimes the cord is wrapped around the baby’s neck. Usually you can just loosen the cord and slip it over the baby’s head or shoulder.
If the cord is very tight and seems to be holding the baby back, you may have to tie the cord in 2 places and then cut it. Use clean string and sterile scissors. Be careful not to cut the baby or the person in labor.
Breech birth
A breech birth is when the baby comes out buttocks first. (See how to check the baby's position before birth.) If this is a first baby, it may be best to have the baby in the hospital. If it must be at home, try to have an experienced midwife or doctor there to help.
What to do for a breech birth: |
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| 1. Stop the person in labor from pushing until you see the baby’s bottom at the vagina. It is very important for the cervix to be fully open. | ||
| 2. Help the person in labor get into a standing squat position. |  | |
| Or if they are unable to squat, help them move their bottom to the edge of the bed as soon as the baby’s legs or bottom come out. |  | |
| 3. Encourage them to push the rest of the baby’s body out slowly. The legs usually fall out but you may need to reach inside the vagina to bring them out. |  | |
| 4. Gently loosen the cord a little so it does not get pulled tight later. If the cord is under the pubic bone, move it to the side where the flesh is softer. |  | |
| 5. Wrap the baby’s body in a dry warm cloth. This will help you hold the baby better and will keep the baby from trying to breathe before the head is born. (In the rest of the pictures, we will not draw the towel. This is so that you can see better. But in a real birth, keep the baby wrapped while you deliver it.) |  | |
| 6. Have a helper put pressure on the pubic bone (not the abdomen). This is to keep the baby’s head tucked to its chest, not to push the baby out. Carefully guide the baby’s body down to deliver the top shoulder. Hold the baby by the hips or legs. Be careful! Pressure on the baby’s back or abdomen can injure its insides. You may need to put your fingers inside the vagina to bring the arms out. Try to grasp the arms by following them down from the shoulder. Bring the arm across the chest by gently pulling on the elbow. Deliver the top shoulder. |
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| 7. Carefully lift the baby to deliver the back shoulder. |  |
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| 8. The baby now needs to turn so it faces down towards the person in labor’s bottom. You may wish to support its body with your arm, placing your finger in the baby’s mouth to help the head stay tucked. This is because when the baby’s chin is tucked to its chest, it passes more easily through the hip bones. |  |
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| 9. Lower the baby until you can see the hairline on the back of the neck. Do not pull the baby! Do not bend the neck or it may break! |  |
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| 10. Keep the baby’s head tucked in while you raise the body to deliver the face. Let the back of the head stay inside the vagina. |  |
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| 11. The person in labor should relax, stop pushing, and “breathe” the baby out. The back of the head should be born slowly. If it comes too fast, the baby could bleed in the brain and die or be severely injured. |  |
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Too much bleeding (hemorrhage)
Some bleeding after birth is normal. But bleeding is a serious problem when it does not stop within one day (24 hours) after birth, or if it is heavy (500 ml, or about 2 cups). Bleeding is heavy when someone soaks through 2 pads or cloths in an hour.
TRANSPORT!
What to do:
1. Take the woman to a hospital.
2. While you are on the way, do the following.
For too much bleeding before the placenta comes out:
- Have the person squat and push the placenta out.
- Have the person pass urine.
- Put the baby’s mouth to the parent’s nipple to start suckling. If the baby will not suckle, have the person roll their nipples or have someone else roll the person’s nipples. This will help the womb contract and push the placenta out.
- You can also give 10 Units of oxytocin by injection in the buttock or thigh.
If the bleeding starts after the placenta comes out:
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| Rolling the nipples can help the womb contract and stop bleeding. |
- Have the person pass urine.
- Keep the person lying down and put the baby to their nipple. If the baby will not suckle, try rolling the person’s nipples. This will make the womb contract and stop bleeding
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- Firmly rub or squeeze the top of the womb (near the navel) until the womb becomes hard. Keep rubbing until the bleeding has stopped.
- If the womb does not become hard after a few minutes of rubbing, or if bleeding continues, give medicine to stop the bleeding
| Medicines to stop bleeding from the womb after the placenta is out | ||
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| Medicine: | How much to give: | When and how to give: |
| oxytocin | 10 units | inject in the side of the thigh muscle |
| If bleeding has not stopped after 30 minutes, give one of the other medicines below. | ||
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| ergometrine | 0.2mg | inject in the side of the thigh muscle |
| You can give this dose again in 15 minutes if bleeding does not stop, and then repeat the dose every 4 hours as needed. Do not give more than 5 doses of ergometrine (1.0 mg total). Do not give ergometrine to someone with high blood pressure. | ||
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| misoprostol | 800 mcg (micrograms) | dissolve in mouth then swallow. If she cannot swallow, insert in rectum. |
| Let the tablets dissolve under the tongue for 30 minutes and then swallow what is left. | ||
| If you give misoprostol in the rectum, wear a glove while putting in the pills, then throw the glove away and wash your hands. | ||
| Also see more information about medicines to stop bleeding. | ||
TRANSPORT!
If bleeding continues, take the person to the health center or hospital. Send 2 family members along to give blood if needed. In the meantime, watch for signs of shock.
