Second Stage - the mother pushes (bears down) with the contractions of the womb to help the baby through the birth canal and out into the world.

Third Stage - the afterbirth is expelled.

First Stage

In this early part of labor it is often helpful for the mother to keep occupied as long as she does not get too tired. She should be patient and calm, relaxing as the contractions come and go and breathing slowly and deeply during the contractions as they become strong. Emptying the bowels and frequent urination will help to relieve discomfort. The mother will know she is in true labor if she has regular contractions of the womb which are prolonged and become strong and closer together. When she knows the baby is on the way, she should choose a place to have the baby that will be clean and peaceful. She should be able to lie down or sit in a leaning position (with her back well supported).

The following events occur as part of the first stage of labor and delivery.

1. The state of dilation: the first signs may be noticeable only to the mother, low-backache and irregular cramping pains (contractions) in the lower abdomen.
2. As labor progresses, the contractions become stronger, last longer, and become more regular. When the contractions recur at regular 3-4 minute intervals and last from 50-60 seconds, the mother is in the latter part of the first stage.
3. The contractions will get stronger and more frequent. The mother will often make an involuntary, deep grunting, moan with each contraction. The delivery of the baby is now imminent.

What To Do During the First Stage

Those helping the mother should know how to time the contractions. This information will give them an idea as to how far into labor the mother is and how much time remains until the baby comes.

Place a hand on the mother’s abdomen just above the umbilicus. As contractions begin you will feel a hardening ball. Time the interval from the moment the uterus begins to harden until it completely relaxes.

Time the intervals in minutes between the start of one contraction and the start of the next contraction. As labor progresses this time will decrease.

Walking or standing tends to shorten labor, so if that feels comfortable to the mother, let her. Also, if she becomes hungry or thirsty, let her eat or drink small amounts of food, fruit juice, or suck on ice chips.

Don’t Leave the Mother Alone

Make no attempt to wipe away vaginal secretions, as this may contaminate the birth canal. The bag of water may rupture during this stage of labor and blood tinged mucous may appear.

At the end of the first stage, the mother may feel tired, discouraged and irritable. This is often referred to as "transition" and is the most uncomfortable part of labor and such feelings are perfectly normal. The mother may have a backache, may vomit, may feel either hot or cold (or both at the same time), she may tremble, feel panicky or scared, cry or get very cross with her husband and birthing attendants. She may even announce that she has changed her mind and is not going through with it. At this time she needs plenty of encouragement and assurance that things are proceeding normally and that her feelings are normal.

Birth attendants, the husband, and others present at the labor and birth should have a cheerful, calm appearance. Nervousness, panic, or distressing remarks can have an inhibiting effect on a laboring woman. Comments on how long the labor is lasting, how pale or tired the woman looks can have a terrible effect on her morale. Even talking quietly can irritate a woman having an intense contraction because it is hard to concentrate on relaxing when there is noise in the room.

Relaxation is very important. A woman’s husband or labor coach should instruct her to go limp like a rag doll and breath deeply, making her tummy rise and fall. This is called abdominal breathing. Begin each contraction with a deep breath to keep the tissues (of both mom and baby) oxygenated. Observe the kind of breathing you do when you are nearly asleep and try to simulate it. Help her to relax her hands, face, legs etc. if you see that they are tense. Tenseness in the body fights the contractions and intensifies the sensations of "pain." Relaxation helps a woman to handle the contractions easier and have a faster labor. Sometimes a woman will breathe too fast and get tingling sensations in her hands and feet. She needs to be coached to slow down her breathing. You can have her follow your breathing until the tingling goes away.

Firm hand pressure on the lower back by those attending the mother may help to relieve the back ache. Alternately, the mother may prefer to lean her back against a firm surface. Deep rhythmical breathing helps to relieve annoying symptoms. The discomfort seldom lasts for more than a dozen contractions.

When the womb is almost fully opened the baby will soon enter the birth canal, and there will be a vocalized catch in the mother’s breathing when she has a contraction. The will signal the onset of the second stage.

Second Stage

The contractions of the second stage are often of a different kind. They may come further apart and the mother usually fells inclined to bear down (push) with them. When she gets this feeling she should take a deep breath as each contraction comes, hold her breath and gently push. There is no hurry here. The mother should feel no need to exert great force as she pushes. She may want to push with several breaths during each contraction. After it passes, a deep sigh will help her recover her breath. She should then rest until the next contraction. She may even sleep between contractions.

Some general instructions for the second stage of labor:

1. Be calm! Reassure the mother and be prepared to administer first aid to both the mother and baby. (Possible respiratory and cardiac resuscitation for the baby and hemorrhage control and prevention of shock for the mother may be needed).
2. Discourage onlookers from crowding around the mother.
3. Use sterile materials or the cleanest materials available. Clean towels or parts of the mother's clothing can be used. Place newspaper under the mother if nothing else is available. If she must lie on the ground, place a blanket or other covering under her.
4. In order to prevent infection, refrain from direct contact with the vagina.
5. Prepare for the delivery by assisting the mother to lie on her back with the knees bent and separated as far apart as possible. Remove any constricting clothing or push it above her waist.
6. When the baby's head reaches the outlet of the birth canal, the top of the head will first be seen during contractions but will then become visible all the time. The mother will now feel a stretching, burning sensation. She must now no longer push during the contractions, and to avoid this, should pant (like a dog on a hot day). This will allow the baby's head to slide gently and painlessly out of the canal. If possible allow the head to emerge between contractions. This will prevent the mother's skin from tearing and will minimize trauma to the baby's head. It is important that the mother pant instead of pushing until both of the baby's shoulders have emerged.

Delivery of the Baby

As the baby is coming down the birth canal, keep the perineum red or pink by massaging with warm olive oil (if none is available simply massage the area with your hand). Any place that gets white will tear more easily so keep massaging and keep all areas red. Use olive oil on the inside too and pay special attention to the area at the bottom, as that is the most common place to tear. Do this massage during a contraction when it will not be noticed or it may irritate some women.

You can support under the perineum with your hand on top of a sterile gauze pad or washcloth. Do not hold it together, just support it so the baby's head can ease out. The other hand can gently press with the fingers around the baby's head so it won't pop out too fast causing tearing. As the baby's head is born, support it with your hand so the face doesn't sit in a puddle of amniotic fluid. Gently wipe the face with a clean or sterile washcloth. Check quickly around the neck for the cord. If you feel it, just hook it with your finger and pull it around the baby's head. Check again. Some are wrapped more than once. If the cord is so tight it cannot be slipped over the baby's head, just wait until the baby is born to untangle it. Most cords are long enough to permit this. IF the cord is too short to permit the baby to be born, it has to be cut and clamped and the baby delivered rapidly. In this situation the baby may be in distress because the oxygen supply was cut off prematurely. With the next contraction, one of the shoulders comes and then the whole body slips quickly out. IF several contractions have passed without a shoulder coming, you may have to slip two fingers in and try to find an armpit. With one or two fingers hooked under the armpit, try to rotate the shoulder counterclockwise while pulling out. Usually this does it.

As the baby's head emerges, it is usually face down. It then turns, so that the nose is turned towards he mother's thigh. Support the baby's head by cradling it in your hands. Do not pull or exert any pressure. Help the shoulders out. For the lower shoulder, support the head in an upward position. As the shoulders emerge, be prepared for the rest of the body to come quickly. Use the cleanest cloth or item available to receive the baby.

Make a record of the time and approximate location of the birth of the baby.

With one hand, grasp the baby at the ankles, slipping a finger between the ankles. With the other hand, support the shoulders with the thumb and middle finger around its neck and the forefinger on the head. (Support but do not choke). Do not pull on the umbilical cord when picking the baby up. Raise the baby's body slightly higher than the head in order to allow mucous and other fluid to drain from its nose and mouth. Be Very Carefulas newborn babies are very slippery.

The baby will probably breathe and cry almost immediately.

If the baby doesn't breathe spontaneously, very gently clear the mouth of mucous with your finger. Stimulate crying by gently rubbing its back. IF all this fails, give extremely gentle mouth-to-mouth resuscitation. Gently pull the lower jaw back and breathe gently with small puffs--20 puffs a minute. If there seems to be excess mucous, use your finger to gently clear the baby's mouth.

The mother will probably want to hold the baby. This is desirable. If the umbilical cord is long enough, let her hold the baby in her arms. If the cord is short, support the baby on the mother's abdomen and help her hold it there.

It is of benefit to the baby and makes the afterbirth come with less bleeding if the baby can be allowed to suckle at the breast as soon as it is born. The cord should not be cut until the afterbirth has completely emerged.

Third Stage

The placenta delivery or afterbirth is expelled by the womb in a period of a few minutes to several hours after the baby is born. No attempt should be made to pull it out using the cord. Immediately following the afterbirth, there may be additional bleeding and a few blood clots. The womb should feel like a firm grapefruit just below the mother's navel. If it is soft, the baby should be encouraged to nurse, and the mother may be encouraged to gently massage the womb. These actions will cause it to contract and lessen the chances of bleeding.

If hemorrhaging occurs, do the following:

1. The uterus should be gently massaged to keep it hard.
2. The woman should lie flat, and the bottom of the bed should be elevated.
3. Put a cold pack (such as a small towel dipped in cold water and wrung out) on the lower tummy to irritate the uterus to contract.
4. Put pressure on the perineum with several sanitary napkins and the pressure of your hand.
5. Most importantly, have the baby nurse. Sucking stimulates the uterus to contract.

Another problem to be alert for is shock. Symptoms of shock are vacant eyes, dilated pupils, pale and cold or clammy skin, faint and rapid pulse, shallow and irregular breathing, dizziness and vomiting. If you notice any of these symptoms, keep the woman warm, slightly elevate her feet and legs, use soft lights, and talk softly and calmly to her.

The baby has some danger of getting an infection through the cut cord, so it should not be cut until sterile conditions are available. If there is a possibility of getting medical help within a few hours, do not cut the cord but leave it and the afterbirth attached to the baby. If there will be no medical help, wait until the afterbirth is out, or at least until the cord is whitened and empty of blood. The cord should not be cut until it quits pulsating so the baby can have a transition time before he absolutely has to breathe on his own. As long as the cord is pulsating, the baby is still receiving oxygen from his mother.

If the cord is long enough, the baby can be put on his mother's tummy so she can hold him and talk to him. IF not, the father should touch him and talk to him. After the cord has stopped pulsating and has become limp it can be clamped or tied about one inch from the baby's tummy with a cord or sterile cloth and then cut.

As the placenta separates from the uterus, the cord will appear longer. Wait for the delivery of the placenta. It will usually be about 10 minutes or longer before the placenta is delivered.

Never pull on the cord. When the placenta appears, grasp gently and rotate it clockwise. Then tie the cord in two places--about six inches from the baby--using strips of material that has been boiled or held in a hot flame.

The placenta and attached membranes must be saved for a doctor's inspection. Leaving the cord and placenta attached to the baby is messy but safe. Save all soiled sheets, blankets, cloths, etc., for a doctor's examination. Check the amount of vaginal bleeding; a small amount (1 to 2 cups) is expected. Place sanitary pads or other sanitary material around birth areas. Then cover mother and baby but do not allow them to overheat. Continue to check the baby's color and respiration. The baby should not appear blue or yellowish. When necessary, gently flick your fingers on the soles of the baby's feet; this will encourage it to cry vigorously.

The mother will probably need light nourishment and will wish to rest and watch her baby. She should keep her hand away from the area surrounding the birth outlet. If uncontaminated water is available, she may wish to wash off her thighs. She may get up and go to he bathroom or seek better shelter. All care should be taken to avoid introducing infection into the birth canal. The mother can expect some vaginal discharge for several days. This is usually reddish for the first day or so but lightens and becomes less profuse within a few days.

Stay with the mother until relieved by competent personnel. This is a relatively dangerous period for the mother, as hemorrhage and shock may occur. Almost all emergency births are normal. The babies typically thrive and the mothers recover quickly. It is very important when assisting with an emergency delivery that you continually reassure the mother and attempt to keep her calm.

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