Unexpected births was written and edited by Dermot Mora, a registered medical practitioner who, as a general practitioner, has delivered hundreds of babies both throughout Australia, New Zealand and the Pacific Islands (including one in a henhouse with a rooster perched on his shoulder - but that’s another story).

More latterly, as a specialist, he has ruffled fewer feathers diagnosing countless birth situations of all kinds in impeccably professional surroundings.

Unexpected births fall into two broad groups.

The first arise from VERY RAPID LABOUR, often resulting in delivery on the way to the hospital. Usually there is little to worry about; the outcome for such births is almost uniformly excellent.

The most useful ‘piece of equipment’ is a mobile phone, or a helpful taxi-driver, to call up emergency services for directions.

If help is close by, nothing need be done except to look after the babe. If it’s in a built-up area and traffic is slow, the umbilical cord may be tied if there’s something handy. If this is done, tie the cord at least 20 cm (about eight inches) from the infant’s body. (There is no need to cut the cord when mother and newborn are on the way to nearby sterile help).

If the placenta comes out by itself, well and good.

If help is, say, half an hour away, gentle, steady pulling on the cord, along with gentle pressure on the top of the uterus will help deliver the placenta.

The second situation confronting someone inexperienced is the UNINTENDED, OFTEN PREMATURE labour, in an unplanned or unforeseen situation.

In such a situation, distance or some other factor may mean transport to assistance is not likely to happen before the babe is born. (But call for emergency help anyway).

This is a different kettle of fish as the labour could be long and difficult - and yet, may be over before help arrives. The baby may be small, premature, and/or exhausted and limp.

There will be time for some elementary preparation, which really only means scrubbing hands and boiling up a pair of scissors to cut the cord and tape, or something like it, to tie it afterwards. (In a remote area this makes handling the baby easier).

Help with the placenta may be necessary if it does not push out within ten minutes or so. This means a gentle but steady pull, just enough to put tension on the cord - not enough to cause it to stretch.   

Complications

Incomplete Delivery

Either the head or breech comes out and progress stops. In the city-taxi kind of scenario, keep going for help. Emergency services include police so they may clear the way. In the remote-home or similar situation, maintain steady pulling, not jerking of the baby parallel to the bed will hopefully succeed - but emergency help will be required.

Maternal Bleeding

Usually, bleeding from the mother ceases after delivery of the placenta. If it doesn’t, get to the hospital as quickly as possible. Pressing the uterus might help lessen the bleeding.

Reviving The Baby

Most newborns breathe fairly quickly but if breathing doesn’t start within a minute gentle mouth-to-mouth resuscitation is the best method in an emergency. A baby has a lot of built-in immunity from its mother and is unlikely to catch anything.

DON'TS

• Don’t jerk. Any actions need to be firm and gentle at the same time.
• Don’t tie the cord close to the baby.
• Don’t panic. The human race would not exist if we didn’t get it right naturally most of the time!

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Every labour is different. Situations vary from woman to woman and from labour to labour.
Broken down into three stages, the first begins with the opening of the cervix to its full capacity; the second involves the baby pressing down through the birth canal (the vagina) culminating in birth; and the third is when the placenta and uterus lining are expelled.

The first stage of labour is generally the longest, taking an average of 8-16 hours for a first baby and 3-10 hours for a second or subsequent baby.
As a pregnancy nears its end, the cervix becomes softer and thinner and shorter in a process known as “ripening”. This is followed by the opening of the cervix known as “dilation” and is estimated in centimetres.

Once dilation reaches 2-3 cm, labour is said to be “established,” and said to be “progressing” as it continues to open.
Full dilation is estimated to be 10cm.

Spontaneous labour at full term signals that both your body and baby ready for birth. The hormone relaxin prepares muscles and ligaments and copper levels, which have risen steadily during the latter stages of pregnancy, may act as a trigger for the initiation of labour. High copper levels also encourage increased zinc in the uterus.
In a normal, unmedicated labour, the body produces endorphins. These are morphine-like substances that bring about a sense of wellbeing and offer some protection from the pain of contractions.

The First Stage of Labour

If you are expecting your first baby, you may notice pressure in your groin and on your bladder beginning up to four weeks before the birth. Your baby’s head will become engaged in our pelvis in preparation for labour.
The first stage of labour begins with the loss of the mucus plug from the entrance of the cervix. This will be bloodstained or pinkish in colour and is called a ‘show’, and may occur several days before labour begins. This is completely normal though a large amount of blood loss is not. In such a case, contact your doctor or midwife immediately.

The amniotic sac may leak or break and the waters either trickle or gush out, commonly known as the waters breaking. The amount of fluid lost will depend on how well engaged your baby’s head is. The amniotic fluid replenishes every three hours so there is no danger of your baby’s welfare being threatened.
Once the contractions have begun, they will become more regular and closer together.

A contraction occurs when the muscles in the womb contract and the pressure within the womb wall rises then falls. During the contraction, the blood supply to the placenta, and therefore the baby, decreases but resumes rapidly once the contraction is over. A normal healthy baby will cope well during this natural process. During this stage, contractions will occur 5-20 minutes apart and last 30 – 60 seconds in duration.

Some women experience ‘false labour’ where contractions start then stop for a period before beginning again. Some women experience vomiting and diarrhoea which are normal symptoms of your body purging.

As the contractions strengthen and the interval between them decreases, you may find yourself retreating into a meditative state. Your breathing pattern may become your focus and your method to deal with the pain.

The muscles at the top of your uterus are pressing down on your baby’s bottom and his head is pressing against your cervix. As the baby’s head descends, it exerts pressure on the cervix, assisting further dilation.

Dilation of the cervix may not occur at a constant rate. Usually, the dilation from 1-5cm takes much longer than from 5-10cm. Generally, the stronger and longer the contractions, the more responsive the cervix will be in dilating.

Contractions are generally at their strongest near the end of the first stage of labour as the cervix becomes more dilated. Once dilation reaches 10cm, the first stage is complete.

Transition

Transition is the point when the labour reaches a peak before shifting down a gear. This lull can last for an hour or two or be over in a flash, though is usually longer during the first labour. There may be feelings of rectal pressure and even feelings of nausea or vomiting.

The Second Stage of Labour

Now begins the second stage when you will begin to push. Contractions will occur 3-5 minutes apart and last for as long as 60-90 seconds. You will probably have an overwhelming urge to bear down and press the baby through the birth canal. During the descent, the rotation of the baby’s head is assisted by powerful contractions, stretching the vagina wide open to accommodate its passage. The bones of its skull are soft enough to allow a little flexibility.
The head and the body are like two balls moving against each other, the largest diameter being that of its head. The body’s trunk will have its limbs tucked tightly in. The natural action of a contracting uterus will mould the baby into the right shape for its journey through the birth canal.

This stage of labour has been described as the most intense, thrilling and passionate of all, and for some women it is the nearest thing to overwhelming sexual excitement. Some women say that your reaction, less a rational decision, is more of a natural response sweeping through your body. You are encouraged to follow the natural breathing pattern and trust the spontaneous feelings.

Some people think it is a good idea to hold your breath then push frantically, however it’s been found that holding your breath is not only exhausting for the mother, but can be dangerous for the baby in that it reduces the oxygen content of the blood.

As the baby’s head passes through the bony pelvic outlet, the head must twist sideways slightly then to a backwards-facing position again before becoming visible. Seen for the first time, it may look more like a wrinkled walnut than a baby’s head. When the widest part of the baby’s head is at the birth opening, you will feel stretched to your utmost. This is known as the “crowning”. It is important not to push as this stage, despite wanting to, as you may tear the perineal tissue.

The doctor or midwife may consider it necessary to perform an episiotomy at this stage. If you do not wish to have one, say so.
To avoid tearing, you will need to begin intense breathing before the head crowns in a bid to “breathe the baby out” rather than pushing. In this way it may slip forwards. The doctor or midwife will check to see that the umbilical cord is free of the neck and may insert a catheter into the baby’s mouth to suck any mucus out.

The head may look sticky with mucus and violet or purple in colour though this is normal as it has yet to take its first breath to oxygenate its blood.
Once the head is free, it will turn to align with the shoulders which are still inside. You may be asked for a push to free the shoulders. Next the body will slide out and the baby is born. This is often accompanied by a great gush of water, followed by a baby breathing and crying with limbs lashing about.

The baby may be covered in vernix, a creamy-like substance that protects the baby’s skin while in the uterus. Its head may be oddly-shaped, asymmetrical and moulded by the birth canal, with a receding forehead and chin. Its face may have little red marks around the eyes and eyelids and its nose may seem flattened. The body, still attached by the umbilical cord, may see small in comparison with the head, though the genitalia may seem extraordinarily large. This is a normal looking baby.

The Third Stage of Labour

All that remains now within the uterus is the placenta, the attached cord and the remnants of the pregnancy sac. Although you may not feel it, the uterus continues to contract causing the placenta to peel off from the uterine wall.

A naturally occurring hormone called oxytocin is produced within the body to help this process. The squeezing of the uterine wall closes off the supply to the blood vessels, preventing excessive bleeding from the wall and keeping blood loss at a minimum.

When the placenta is detached, the doctor or midwife may gently pull on the cord and you may be asked to take a breath and bear down to assist.
After it slides out, it will be closely examined by the person who delivered the baby to check that every part is there. This is to avoid any section being left within the womb, which if left unnoticed, could cause infection during postpartum.

Often during a hospital birth, it is a common practice to inject oxytocin into a muscle or drip as soon as the baby is born to induce the delivery of the placenta. The potential for haemorrhage immediately after childbirth is at its greatest and this usually increases with successive pregnancies.
In the nineteenth century, excessive bleeding at this stage was a common cause of women dying in childbirth.

Today’s routine administration of an oxytocin injection at birth has meant that far fewer women suffer from postpartum haemorrhage and if they do, it is likely to be less severe, often without need for a blood transfusion.

The progressing dilation of the cervix during the stages of labour.

Post Partum

The Placenta

The placenta will look like a piece of raw liver with a rough side, that which was attached to the uterine wall, and a velvety smooth soft side, against which the baby was cushioned. It will have an intricate network of blood vessels which during pregnancy, was the baby’s life support system supplying oxygen and nutrients.

The significance of the placenta in its role of creating and sustaining life has long been recognised by tribal cultures. Some choose to mark its importance with a burial in a sacred place, creating what is considered to be a “place to come home to”.

Cutting the Cord

Once the baby breathes air, it has not further need for the placenta or the umbilical cord. Within a few minutes of the birth, once the cord has stopped pulsating, the cord can be clamped with forceps. Clamps are usually placed at two points, and with a pair of sharp, sterile scissors, the cut is made between these points.

A clamp is then moved closer to the umbilicus (tummy button) so the excess cord can be trimmed.
There is no hurry for this to be done and there may be some advantages for the baby in waiting for the blood within the cord to drain into its circulation.

Cord Blood Collection

The blood within the umbilical cord is considered to be rich in special blood cells called “stem cells” also found in bone marrow.
Stem cells can be used to successfully treat children with leukaemia (cancer of the blood cells).

For this reason, in some countries you may be asked if you would care to donate to a cord blood bank. The collection has to be planned beforehand so that the cord can be cut quickly and the blood collected into a special container by a trainer technician so it can be immediately frozen. The collection process is painless and harmless for both the mother and newborn.

If you are asked to donate to the cord blood bank, consider the request carefully.

Repairs to the Perineum

Should your perineum require stitches, suturing is done under local anaesthetic and can often take a long time as careful precision is taken in joining together the underlying layers of muscle.

An icepack can help reduce swelling.

The bloodstained vaginal discharge common following childbirth is called lochia. Some women experience it for just a few days though for others, it may last as long as five or six weeks. 

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