Hesperian Health Guides

Difficult Births

Cord comes out before the baby

If the cord comes out before the baby's head, the cord gets squeezed when the head comes down. The baby can die or get brain damage from too little oxygen.

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cord showing at opening of vagina
What to do:

If the baby is coming very fast and is almost born, have the mother push as hard as she can in a squatting position and get the baby out.

a pregnant woman with her head, arms, chest, and knees on the floor


If the baby is not coming quickly, put the mother in the knee-chest position, help her to stop pushing, and get her to a hospital. The baby needs to be born by operation.


a woman's body, showing the womb with two babies in it

When a mother is carrying more than one baby, it is best for her 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 a woman give birth to twins here is what to do:

the first baby's cord coming out of the mother after being cut
Tie this end
of the cord too.
What to do:
  1. Deliver the first baby just as you would any single baby.
  2. 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.
  3. DO NOT give any injections.
  4. Give the first baby to the mother to begin breastfeeding. This will help get the second baby born.

  6. 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.

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 clean scissors. Be careful not to cut the baby or the mother.

Breech birth

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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 for the woman to have the baby in the hospital. If she stays at home, try to have an experienced midwife or doctor there to help her.

a woman leaning on pillows, eyes closed and knees bent, with a pool of blood between her legs

Too much bleeding (hemorrhage)

It is normal for a woman to bleed a little after childbirth. But bleeding is a serious problem if it does not stop within an hour after birth, or if there is a lot of blood--more than 2 cupfuls, or enough to soak through 2 thick pads in an hour.


What to do:

1. Take the woman to a hospital.

2. While you are transporting her, do the following.

For too much bleeding before the placenta comes out:

  • Ask the mother to squat and push the placenta out.
  • Ask her to pass urine.
  • Put the baby to the mother's breast to start suckling. If the baby will not suckle, have the mother roll her nipples or have someone else suck on her breasts. This will help her womb contract and push the placenta out.
  • You can also give 10 units of oxytocin by injection in the buttock or thigh, or give 800 mcg (micrograms) of misoprostol under the tongue, one time only.

If the bleeding starts after the placenta comes out:

a woman rolling her nipple between thumb and finger
Rolling the nipples can help the womb contract and stop bleeding.
  • Ask the mother to pass urine.
  • Keep the mother lying down and put the baby to her breast. If the baby will not suckle, try rolling the mother's nipples. This will make the womb contract and stop bleeding.
a woman lying down, baby on breast, while another woman rubs the top of her womb
  • Firmly rub the top of her womb at the level of her 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
Medicine: How much to give: When and how to give:

You can give this dose again in 20 minutes if bleeding does not stop.
10 Units

inject in the side of the thigh muscle

ergometrine 0.2mg inject in the side of the thigh muscle
ergometrine pills 0.2mg give by mouth
You can give ergometrine every 2 to 4 hours for severe bleeding, or every 6 to 12 hours for less severe bleeding, but continue to give the medicine until bleeding as stopped and the womb is hard, usually about 48 hours.
Pills do not work as quickly as injections. Do not give ergometrine to a woman with high blood pressure.
misoprostol800 mcg (micrograms) dissolve in mouth then swallow. If she cannot swallow, insert in rectum.
Have the woman dissolve tablets against her cheek or under her tongue for 30 minutes and then swallow the remaining parts.
If you give misoprostol in the rectum, wear a glove while inserting the pills, then throw the glove away and wash your hands.
Also see more information about medicines to stop bleeding.


If the mother continues to bleed, take her to the health center or hospital. Send 2 family members with her to give blood if needed. In the meantime, watch her for signs of shock.

three people helping a woman who has lost a lot of blood
She has been bleeding too long. We must take her to the hospital. I'll bring the baby.
I'll carry her.
I feel faint...
I'll get the truck.

This page was updated:23 Oct 2019