Most women in the world today do not get prenatal care or trained help during birth. They usually have their babies at home with the help of a local midwife or a family member. This chapter has information for both the pregnant woman and her helpers, about care during pregnancy, and care both during and after the birth.
For more complete information about caring for women in pregnancy and helping them with both normal and difficult births, see the Hesperian Foundations A Book for Midwives (for how to order it, see the last page of this book).
Every pregnant woman needs good health, good food, and the love and support of her family and community. Many women feel very healthy during pregnancy and do not have difficult births. Most babies are born healthy.
Without water, the crops would die; and without children, life in the community could not continue.
- Mixtec saying, Mexico
At the same time, pregnancy can be one of the main dangers a woman faces in her life. About half a million women die each year from problems of pregnancy and birth (this is also called maternal mortality), mostly in poorer countries.
Most of these deaths could be prevented with basic care. This chapter has information that can help pregnant women care for themselves, or help others care for them.
HOW TO TELL IF YOU ARE PREGNANT
· You miss your monthly bleeding.
· Your breasts feel sore and grow bigger.
· You feel sick to your stomach and sometimes vomit.
· You have to pass urine more often.
· You feel tired.
HOW TO KNOW WHEN THE BABY IS DUE
Add 9 months plus 7 days to the date when your last normal monthly bleeding began. Your baby will probably be born any time in the 2 weeks before or after this date.
Many women know when their baby will be born by counting the passing of 10 moons.
If you can take good care of yourself while pregnant, you are more likely to have a safe pregnancy and birth and a healthy baby.
· Try to eat enough nutritious foods. Good nutrition gives strength, prevents infection, builds a healthy baby, and helps prevent too much bleeding during birth. Remember that you are feeding both yourself and your baby. Use iodized salt to make sure your baby will not suffer from mental slowness.
· Sleep and rest whenever you can. If you work standing up, try to sit or lie down several times during the day.
Do your daily work...
... but rest whenever you can
· Go for prenatal (before-birth) check-ups to make sure there are no problems, and to find problems before they become serious. If you have never had a tetanus immunization, get one as soon as you can. Get at least 2 before the end of the pregnancy.
¨ Read about the Danger signs during pregnancy, to learn when it is important to see a health worker.
· Keep clean. Bathe or wash regularly and clean your teeth every day.
· Practice squeezing exercises, so your vagina will be stronger after the birth.
· Try to get daily exercise. If you sit down at work, try to walk a little every day. But try not to tire yourself.
· Get treatment if you think you have a sexually transmitted disease (STD) or other infection.
· Avoid taking modern or plant medicines, unless a health worker who knows you are pregnant says it is OK.
· Do not drink alcohol or smoke or chew tobacco during pregnancy. They are bad for the mother and can harm the developing baby.
· Avoid pesticides, herbicides, or factory chemicals. They can harm the developing baby. Do not touch or work near them, or breathe in their fumes. Never store food or water in their containers.
· Stay away from a child with a rash all over its body. It may be caused by German Measles, which can harm the baby.
¨ If there is malaria where you live, sleep under a bed net to avoid being bitten by mosquitos.
When you are pregnant your body changes and you may have some of the following common problems. But remember, most of these problems are normal in pregnancy.
SICK STOMACH (NAUSEA)
Although it is often called morning sickness, during pregnancy you may feel sick to your stomach at any time during the day or even all day long. It usually goes away by the end of the 3rd or 4th month.
What to do:
· Drink a cup of ginger or cinnamon tea 2 or 3 times a day, before meals.
· Eat small meals often, and avoid foods that are oily or hard to digest.
· Lick a lemon.
· Ask the midwives in your community for good local plant medicines or remedies.
To help with morning sickness...
... try eating a biscuit, a tortilla, a piece of bread, a chapati, or a little rice or porridge when you wake up in the morning.
See a health worker if you vomit so much that you cannot keep any food down, or if you are losing weight. Also watch for signs of dehydration.
HEARTBURN OR INDIGESTION
Heartburn causes a burning feeling in the throat and chest. It is most common in later pregnancy, after eating or when lying down.
What to do:
· Eat several small meals instead of one large meal.
· Avoid spicy or oily foods.
· Drink plenty of water and other clear liquids.
· Try not to lie down right after eating.
· Sleep with your head higher than your stomach.
· Take a cup of milk or yogurt, some bicarbonate of soda in a glass of water, or calcium carbonate (antacid).
DISCHARGE FROM THE VAGINA
During pregnancy, it is normal to have more white discharge than usual from the vagina. But if the discharge itches, burns, or has a bad smell, you may have an infection of the genitals, which should be treated. If the discharge is bloody or has mucus in it, or if there is a lot and it looks like water, see a health worker. You may be starting labor too early.
SWOLLEN VEINS (VARICOSE VEINS)
Blue swollen veins in the legs and around the vagina are called varicose veins. They are caused by the weight of the growing baby. They can become quite large and painful.
What to do:
· Try not to stand up for too long. If you have to stand, walk in place or move your feet and legs. When you are sitting down, put your feet up as often as possible.
· Be sure to walk every day. If you have a disability and cannot walk, ask someone in your family to help move and exercise your legs.
· If the problem is severe, wrap your legs with cloths. Begin wrapping at the ankles and work up to just below the knee. The bandage should be tighter around the ankle and looser further up the leg. Take off the bandages at night.
Women with swollen veins should try to put their feet up when they can, and wrap their legs if the swelling is very bad.
CONSTIPATION (DIFFICULTY PASSING STOOL)
Pregnancy makes the bowels work more slowly. This can make the stool harder, so it is more difficult to pass.
What to do (these things also help prevent constipation):
· Drink at least 8 glasses of liquid every day.
· Get regular exercise.
· If you are taking iron tablets, try taking only one a day with fruit or vegetable juice. Or skip a few days.
· Eat plenty of fruits, vegetables, and foods with fiber - like whole grains and cassava (manioc) root.
· Do not take laxatives. They only solve the problem for a short while and then you need to take more.
Hemorrhoids are swollen veins around the anus. They often itch, burn, or bleed. Constipation makes them worse.
If you have hemorrhoids, sitting in cool water can help with the pain.
What to do:
· Sit in a basin or pan of cool water to relieve the pain.
· Follow the advice above for preventing constipation.
· Soak some clean cloth in witch hazel (a liquid plant medicine) if you can find it, and put it on the painful area.
· Kneel with your buttocks in the air. This can help relieve the pain.
Pregnant women often get foot or leg cramps - especially at night, or when they stretch or point their toes down. Leg cramps may be caused by not enough calcium in the diet.
What to do:
· Eat plenty of foods that contain calcium, such as milk, cheese, sesame seeds, and green leafy vegetables.
· If your foot or leg cramps:
Low-back pain is caused by the weight of the growing baby.
What to do:
· Ask someone to rub or massage your back.
· Ask your family for help with some of the heavy work.
· Take care to stand and sit with your back straight.
· Sleep on your side with a pillow or rolled up cloth between your knees.
· Do the angry cat exercise for a few minutes, 2 times each day, and whenever your back hurts.
Angry cat exercise
SWELLING OF THE FEET AND LEGS
Some swelling of the feet is normal during pregnancy - especially for women who must stand all day.
What to do:
· Put your feet up as often as you can during the day.
· When resting, lie on your left side.
· If your feet are very swollen, or they are swollen already when you wake up in the morning, or your hands and face also swell, these are signs of danger during pregnancy.
WOMEN WHO HAVE EXTRA RISKS
Women with any of the following problems can have more dangerous pregnancies and births. They should plan to go to a health center or hospital for the birth. If possible, they should try to get prenatal care during pregnancy.
· Weak blood (anemia) makes a woman more likely to bleed heavily (hemorrhage) during birth, become ill after childbirth, or even die.
· Sugar sickness (diabetes) often causes very serious problems for the mother and the baby. The baby can die before birth or sometimes grows very large and gets stuck in the pelvis.
· High blood pressure can lead to severe headaches, fits, and even death.
· Older mothers who have had many babies often have long, difficult labors, and heavy bleeding after the birth.
· Mothers under the age of 17 are more likely to have toxemia (which causes fits), long, difficult labors, babies born too early (premature), and blocked births, which may damage the bladder, vagina, and womb.
· Mothers who had problems with past pregnancies - such as fits, birth by operation, heavy bleeding, a too-early or too-small baby, or a baby born dead - are more likely to have problems in another pregnancy or birth.
· Women with disabilities, especially women with a loss of feeling in the body or difficulty walking, can have problems during both pregnancy and birth.
A woman who is likely to have a dangerous birth should plan to have her baby in a health center or hospital.
Other women who should try to give birth at a health center or hospital
Some women - who have none of the extra risks listed above - are still likely to have dangerous births. These women should also try to give birth at a health center or hospital:
· A woman with a baby in the wrong position for birth at the end of pregnancy can have a long, difficult labor. The mother, the baby, or both may die.
· Women who have been infibulated can have severe tearing of the genitals during the birth. This can cause great pain, heavy blood loss, and infection.
DANGER SIGNS DURING PREGNANCY
In addition to the problems just listed, these danger signs may occur during pregnancy. A woman with any of these signs may be in serious danger and should see a health worker See the next few pages for more about them.
· feeling very weak or tired
· swelling of hands and face, or bad headache and blurred eyesight
Feeling very weak or tired (anemia)
If you feel very weak or tired, you could be anemic. Women who are very anemic are much more likely to have heavy bleeding after the baby is born.
What to do:
· Eat foods rich in iron - meat, fish, chicken, eggs, beans, peas, and leafy green vegetables.
· Take 325 mg of iron 2 times a day, and 1 mg of folic acid once a day, until the baby is born. If you take iron tablets with fruits like oranges, mangoes, or papayas, your body uses the iron better.
Pain in the lower belly (abdomen)
1. Strong, constant pain in the first 3 months may be caused by a pregnancy that is growing outside the womb in the tube, (a tubal pregnancy). As the tube stretches, it causes pain. If the pregnancy grows large enough, the tube will burst and bleed. This is very dangerous. You will bleed inside your abdomen and may die.
Signs of tubal pregnancy:
· missed monthly bleeding, and
· pain in the lower abdomen on one side, and
· slight bleeding from the vagina
· feeling dizzy, weak, or faint
What to do:
Go to the nearest hospital.
¨ Strong pain in the abdomen does not always mean something is wrong with a pregnancy. For information about other possible causes, see Pain in the Lower Abdomen.
2. Strong pain that comes and goes (cramping) in the first 6 months could mean you are losing the pregnancy (having a miscarriage).
3. Strong, constant pain in late pregnancy. This could mean the afterbirth (placenta) is coming off the wall of the womb. This is very dangerous. You could die if you do not get help. Go to the nearest hospital.
4. Pain that comes and goes in the 7th or 8th month could mean you are going into labor too early.
Bleeding from the vagina
1. Bleeding early in pregnancy. Light bleeding from the vagina during the first 3 months of pregnancy can be normal. But if you have pain with the light bleeding, it could mean a pregnancy is developing outside the womb, which is very dangerous. If the bleeding gets heavier and stronger than a normal monthly bleeding, you are probably losing the pregnancy (having a miscarriage).
2. Bleeding later in pregnancy. Bleeding after the first 3 months can mean there is something wrong with the afterbirth (placenta). Both you and the baby are in danger.
What to do:
· Go to the nearest hospital.
· On the way, lie down with your feet up.
· Do not put anything in your vagina.
High fever, especially along with shivering, body aches and severe headache, can be caused by malaria. Treatment for malaria depends on where you live. See Where There Is No Doctor for more information.
Swelling of the hands and face or severe headache and blurred vision (toxemia)
Some swelling in the legs and ankles is normal in pregnancy. But swelling of the hands and face can be a sign of toxemia, especially if you also have headaches, blurred vision, or pains in your abdomen. Toxemia can cause fits, and both you and the baby can die.
What to do:
· Find someone who can check your blood pressure. Go to a health center or hospital if necessary.
· Rest as often as possible, lying down on your left side.
· Try to eat more foods with a lot of protein every day.
· Plan to have the birth in a health center or hospital.
Danger signs of toxemia
· swollen hands and
If a woman has any of the danger signs of toxemia, she needs medical help fast If she is already having fits.
BABY IN THE WRONG POSITION WHEN LABOR STARTS
If the baby is buttocks first (breech) when labor starts, the birth can be more difficult. If the baby is lying sideways when labor starts, the baby cannot be born without an operation.
¨ If the babys head is down, the birth is more likely to go well.
Positions that cause difficult or dangerous births
If the babys head is up, the birth may be more difficult. It may be safer for the mother to give birth in a hospital.
If the baby is lying sideways, the mother should give birth in a hospital. She and the baby are in danger. Birth may not be possible without an operation.
During the last month of pregnancy, it may be possible to change the babys position by lying in this position for 10 minutes, 2 times a day:
Lie on the floor with pillows under the hips. Try to get the hips higher than the head.
Do this exercise every day with an empty stomach, until the baby changes to a head-down position and then stop. The babys position should be checked each week.
· If labor starts and the baby is still sideways, the mother must go to a health center or hospital where the babys position can be changed, or where she can have an operation. Without medical help, the mother and her baby will almost certainly die.
· If labor starts and the baby is still buttocks first.
DO NOT try to change the babys position by hand yourself unless you have been trained to do it and have done it before successfully. You can tear the womb and harm both the mother and the baby.
IF LABOR STARTS TOO EARLY (BEFORE THE 8TH OR 9TH MONTH)
Some babies born too early might not live. A woman may be able to slow or stop labor by lying in bed with her hips raised, and resting until the labor stops (see the picture above). If she can go to a hospital, they may be able to stop the labor. Even if they cannot stop the labor, they can sometimes keep the baby alive.
Prenatal check-ups are important to find and take care of problems early - before they become dangerous. Good prenatal care is not difficult to give and does not require very expensive equipment. Many birth attendants, midwives and health centers, as well as hospitals, can give this care. It can save many lives.
If you are pregnant, try to have at least 3 check-ups:
1. As soon as you think you are pregnant.
2. Around the 6th month of pregnancy.
3. A month before the baby is due.
¨ Prenatal check-ups can help you decide the best place to have your baby: at home, or at a health center or hospital.
A midwife, birth attendant, or health worker will ask about past pregnancies and births, including any problems, such as a lot of bleeding or babies that died. This information can help you both prepare for similar problems in this pregnancy and birth. A midwife may also be able to:
· make sure a woman is eating well enough and suggest ways for her to eat better food, if necessary.
· give iron and folic acid tablets, which help prevent anemia.
· examine the mother, to make sure she is healthy and that the baby is growing well.
· give vaccinations to prevent tetanus, a disease that can kill both mothers and babies.
· give medicine to prevent malaria if it is common in the area
· give tests for HIV and syphilis, along with other sexually transmitted diseases.
What to expect at a prenatal check-up
A birth attendant or midwife should do these things at a prenatal check-up:
· Check the eyelids and finger nails for signs of anemia.
· Check the hands and face for swelling.
· Check blood pressure.
· Check the growth of the baby in the womb. Normally the womb will grow 2 fingers each month. At 4° months it is usually at the level of the navel. If the womb seems too small or too big or grows too fast, it may mean there is a problem.
To check whether the baby is healthy, a midwife may listen for the babys heartbeat. It may be possible to hear it by putting one ear against the womans abdomen, but often you cannot tell the babys heartbeat apart from the mothers. It is easier with a fetoscope. Another sign the baby is healthy is if the mother feels the baby move every day, and if she has felt it move on the day of the check-up.
Checking the babys position
During pregnancy, it is common for a baby to change position several times in the womb. By the end of the pregnancy, the baby should be lying in the womb with its head down. This is the best position for birth. To make sure the baby is head down, feel for the head like this:
1. Have the mother breathe out all the way. Using both hands, feel the baby.
2. Push gently from side to side, first with one hand, then with the other. At the same time, feel what happens to the babys body with the other hand as you push.
3. Just before birth, a baby will move lower in the womb to get ready for birth. So, late in pregnancy, you may not be able to feel the babys head move.
THINGS TO HAVE READY BEFORE BIRTH
A pregnant woman should have these things ready by the seventh month of pregnancy:
¨ If you do not have a new razor blade, you can use rust-free scissors or a knife if you boil them for 20 minutes just before cutting the cord.
These are some additional supplies a midwife or birth attendant may have:
This is also the time to:
· plan transportation in case you need to go to the hospital.
· clean the birth place.
HELPING A WOMAN GIVE BIRTH
If you are pregnant, read this information to know what to expect during labor and after the baby is born. It will also make you better able to help other women during birth.
If you are helping a woman give birth, you can make a big difference in helping her have a safe and healthy birth. Remember that most babies are born without problems.
Stay calm and cheerful. Reassure the mother so that she will not be afraid. Let her know that you trust her ability to give birth.
· Keep your nails clean and cut short.
· Wash your hands with soap and clean water. Let them dry in the air.
· Know which women have extra risks and learn the Danger Signs during Pregnancy. Make sure the mother gives birth in a health center or hospital if she has any of these risks or danger signs.
· Learn the Danger Signs during Labor. Take the woman to a hospital if she has any of these signs.
· Treat her with kindness and respect.
¨ For safe childbirth practice the 3 cleans:
1. Clean hands
2. Clean place to give birth
3. Clean tool to cut the cord
Protect yourself from HIV and hepatitis by wearing clean gloves during a birth. If you do not have gloves, use washed plastic bags.
· Do not put your fingers or anything else in the womans vagina. Checking how much the womb has opened does not help the baby to be born, and may cause a dangerous infection.
· Do not give any medicine to speed up labor or to make labor stronger. These medicines can kill the mother and the baby. (Medicines that cause the womb to contract should only be used to stop bleeding after the baby is born.)
· Do not tell her to push before she is ready. When it is time for the baby to be born, she will feel like she has to pass stool and will start pushing on her own.
· Do not push on the outside of her womb to make the baby come out faster This can tear her womb or cause the placenta to separate from the womb too soon. Both the mother and the baby can die.
These 3 signs show that labor is starting or will start soon. They may not all happen, and they can happen in any order.
1. Clear or pink-colored mucus comes out of the vagina. During pregnancy, the opening to the womb (cervix) is plugged with thick mucus. This protects the baby and womb from infection. When the cervix starts to open, it releases this plug of mucus and also a little blood.
2. Clear water comes out of the vagina. The bag of waters can break just before labor begins, or at any time during labor.
3. Pains (contractions) begin. At first contractions may come 10 or 20 minutes apart or more. Real labor does not begin until contractions become regular (have about the same amount of time between each one).
When any one of these signs occurs, it is time to get ready for the birth. Here is a list of things you can do:
· Let your midwife know that labor is starting.
· Make sure that the supplies for the birth are ready.
· Wash yourself, especially your genitals.
· Continue to eat small meals and drink whenever you are thirsty.
· Rest while you can.
Every birth has these 3 parts.
Stage 1 begins when contractions start to open the cervix and ends when the cervix is fully open. When it is the mothers first birth, this stage usually lasts 10 to 20 hours or more. In later births, it often lasts from 7 to 10 hours. It can vary a lot.
Stage 2 begins when the cervix is open and ends when the baby is born. This stage is usually easier than Stage 1, and should not take more than about 2 hours.
Stage 3 begins when the baby is born and ends when the placenta comes out.
Stage 1: The cervix opens
To make sure that labor is going well, check:
1. How long has the woman been having contractions and how often do they come? At first, they may come every 10 or 20 minutes and last for a minute or less. After some time they will come more quickly - about every 2 to 5 minutes - and each one will last longer, about a minute and a half, until the baby is born. If she has had a contraction every 10 minutes or faster for more than 1 day and 1 night (24 hours) and the baby is not ready to be born, see Too long labor.
2. Have her waters broken? If they have, ask when. If it has been more than a day, see Waters break and labor does not start in a few hours. If the waters are green or brown, see Green or brown waters.
3. Is the baby in a head-down position? Feel the mothers abdomen. If the baby is sideways or breech, you must take her to a health center or hospital.
You can also help the mother by reassuring her that she is doing well and by encouraging her to:
· stay active.
· eat light foods, not heavy or oily foods.
· drink as much sweet liquid and warm tea as she wants.
· pass urine often.
· take deep, slow breaths during contractions, and to breathe normally between them.
· not push until she feels a strong need to push.
Walking helps the womb open. It can also make the pain less and help the mother feel calmer.
During labor, let the woman choose the most comfortable positions. For many years, doctors and some midwives asked women to lie on their backs, but this is often a difficult position for going through labor and giving birth. Encourage a woman in labor to try different positions. Most women find it easier to push the baby out when they are kneeling, squatting or sitting propped up.
Stage 2: Pushing the baby out
Signs that it is time to push (this means the cervix is fully open):
· The mother feels a strong need to push. It may feel like needing to pass stool.
· During contractions, you can see the mothers bottom bulging and you may see the babys head at the opening of the vagina. At first, the babys head moves back inside between contractions.
What to do:
· Stay with the mother all the time and reassure her that she and the baby are doing well.
· Each contraction will come with a very strong urge to push. When the mother feels like pushing, have her take a deep breath and push as if she were passing stool, but with all her strength. Many women find it helpful to moan or groan in a deep voice with the pushes.
· Make sure that everything is going well and is ready for the birth. If the woman has been pushing for more than 2 hours, see Too-long labor,.
Birth of the head
When the babys head stays at the opening of the vagina, even between contractions, it is time for the head to be born:
1. Tell the mother not to push hard, but to give little grunts or little pushes.
2. Allow the head to come out slowly, between contractions. This will help to prevent the mothers skin from tearing.
3. After the head is born, wipe the babys mouth and nose with a clean cloth.
Birth of the shoulders
To help the shoulders come out:
1. Gently hold the babys head and guide it toward the mothers back (away from her abdomen). This lets the front shoulder be born first Never pull or twist the head.
2. The rest of the baby will then come out easily. Be ready! Hold the baby so it does not fall.
Care of the baby at birth
A healthy baby will start breathing, move its arms and legs, and start crying right away. To care for the baby:
· Wipe its mouth and nose with a clean cloth. To help the mucus drain, keep the babys head lower than its body. If there is a lot of fluid or mucus, remove it with a suction bulb.
· Give the baby to the mother right away. Put a clean cloth around both of them. Do this as soon as possible so the baby stays warm.
· Put the baby to the mothers breast immediately. When the baby sucks, the mothers womb tightens and stops the bleeding. This will also help the placenta come out more quickly.
· Tie and cut the cord only when it turns white and stops pulsing. To prevent tetanus, a serious disease that kills many babies, cut the cord close to the babys body.
To cut the cord:
1. When the cord stops pulsing, put 2 clean ties around it, using square knots. Put one tie about 2 finger widths from the baby and put the other one about 2 more finger widths farther from the baby.
2. Cut the cord between these 2 ties with a new razor blade. If you must use something else to cut the cord, make sure it has been boiled for 20 minutes.
Care of the eyes
To prevent infection from gonorrhea, put 1% tetracycline, erythromycin, or chloramphenicol eye ointment in each eye within an hour of birth.
Pull down the lower lid to put a little bit of ointment inside. Putting ointment outside the eye does no good.
Stage 3: The placenta comes out
When the baby is wrapped and at the mothers breast, it is time for the placenta to come out.
Watch the vagina to see when the cord gets longer. This means the placenta is separating from the womb. Also watch to make sure there is no heavy bleeding. When the cord lengthens, tell the mother to push out the placenta. Do not pull on the cord.
If the placenta does not come out right away and there is no bleeding, it is OK to wait up to 1 hour.
Rolling the nipples can help the womb contract and stop bleeding.
To help the placenta come out:
· Have the mother squat and push. If she cannot push, have her blow into a bottle, sneeze, or cough.
· Ask the mother to pass urine.
· Encourage the baby to nurse, or have someone roll the mothers nipples. This will help make her womb contract.
· If nothing else works, give her an injection of 10 milligrams of oxytocin in her hip or thigh.
· If the mother starts to bleed.
Check the placenta
Usually the placenta comes out whole, but sometimes a piece gets left inside. This could cause bleeding or infection later. To see if everything has come out, check the top and bottom of the placenta, and the membranes from the bag of waters.
¨ When the placenta is out, put it in a bowl and check it to make sure it is all there.
If the mother is bleeding, or there seems to be a piece of the placenta or membranes missing, follow the instructions for too much bleeding.
Try to make sure the membranes are all there. You should be able to imagine them fitting together as a sack.
· waters break but labor does
Waters break but labor does not start
Most women will start labor within 24 hours after their waters break. If labor has not started after 1 day and 1 night, the woman and her baby could get a serious infection.
DANGER!! Do not use injections to start labor. They can cause contractions that are so strong that they can kill the woman or the baby.
What to do:
· The mother must not put anything in her vagina. She should not have sex. This could cause an infection.
· If she has a fever or there is a bad smell in the vagina, an infection is starting. She needs intravenous (IV) antibiotics. Even if labor starts, the woman and her baby could die. Go to a health center or hospital.
· Try to get labor started. The woman should swallow 2 tablespoons of castor oil, roll her nipples, or have someone suck them for a while every few hours until labor starts. There may also be special local teas that women use to start labor. If labor still does not start after a few more hours, she should go to a health center or hospital.
Baby lying sideways (transverse)
If labor has started and the babys arm comes out first, it almost always means the baby is sideways. Check the babys position. A baby lying sideways cannot be born without an operation. Do not try to change the position of the baby once labor has started. This can tear the womb or separate the placenta from the womb wall.
What to do:
Take the mother to the hospital.
Bleeding before the baby is born
Some light, pink-colored fluid, or mucus and brown blood during labor is normal. But if the mother is bleeding bright red blood, it could mean that the placenta is separating from the womb wall or is covering the opening of the womb. This is very dangerous.
What to do:
Take the mother to the hospital right away. If possible, start an IV and give her IV fluids.
If the mother has been in good strong labor for more than 1 day and 1 night, or she has been pushing for more than 2 hours without any signs that the baby will be born soon, there may be a problem.
A woman in labor should not see the sun rise twice. - Proverb from Niger
What to do:
If her contractions are not coming every 2 or 3 minutes and lasting for a full minute, she may not be in good labor yet. Encourage her to sleep. If she cannot sleep, ask her to roll her nipples and walk between contractions to help labor get stronger. Encourage her to drink and eat light foods. Fruit juices or tea with sugar can give her energy.
If the mother is getting exhausted and she has been in labor for more than 24 hours, or has been pushing for more than 2 hours, take her to a health center or hospital. She may need medicines to help her labor or an operation for the baby to be born.
Green or brown waters
Brown or green waters can mean that the baby is in trouble.
What to do:
If it is still early in labor or if the mother has not started pushing, it is best for this baby to be born in a hospital.
If the mother is in Stage 2 of labor and the baby is going to be born soon, have the mother push as hard as she can and get the baby out quickly. As soon as the babys head is born, wipe its mouth and nose with a clean cloth or use a suction bulb to suck the mucus out. Keep the babys head lower than its body to help the mucus come out.
Fever is usually a sign of infection.
¨ A woman who is only a little warm may just need to drink more fluids.
What to do:
Touch the womans forehead with the back of one of your hands, and touch your own forehead with your other hand. If she feels a little warmer than you, she may just need fluids. Give her plenty of water, tea, juice, or soda pop. Remind her to pass urine every few hours.
If she feels very hot to touch and she has chills, take her to a health center or hospital. She needs antibiotics right away. Give ampicillin, 500 mg by mouth every 6 hours, or inject 1.2 million Units of procaine penicillin into her buttock or thigh, every 12 hours until you can get to a hospital.
Fits, or very swollen hands and face (toxemia)
If the mother starts to have a fit:
· Put something under her head to protect it, and put her on her left side if possible. But do not try to hold her down.
· Keep her cool.
· Send someone to get emergency transportation and take her to the nearest hospital.
If possible, give one of the following medicines:
· magnesium sulfate, 50% solution. Inject 10 ml into each buttock muscle once. Repeat after 4 hours if needed.
¨ For more information about these medicines, see the Green Pages.
How to give diazepam
A woman having fits cannot swallow pills, and diazepam may not work well when injected into a muscle during a fit. So it is usually best to put either liquid (injectable) diazepam or diazepam pills that have been crushed and mixed with water into the mothers rectum.
Liquid diazepam. Give 20 mg after the first convulsion. If there are other convulsions, give 15 mg after each one.
To give liquid diazepam, first load a syringe and then TAKE OFF the needle.
Put the barrel of the syringe gently into the rectum about 2 inches and empty it inside. Hold the barrel of the syringe in place for at least 5 minutes. It will act as a plug to keep the medicine from coming out. If some fluid leaks out of the anus, it is OK to give 5 mg more.
Diazepam pills. If you only have diazepam pills, you can crush them and mix them with water. The pills will not completely dissolve. Crush 20 mg of pills.
To give the pills, draw the water and pill mixture up into a syringe with the needle already removed, and put it into the rectum - the same as above.
Cord comes out before the baby
If the cord comes out before the babys head, the cord gets squeezed when the head comes down. The baby can die or get brain damage from too little oxygen.
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.
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.
Babys shoulders get stuck
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:
1. Have the mother get on her hands and knees, and push. The stuck shoulder will usually slip out and the baby can be born.
2. If the hands-and-knees position does not work, bring the mothers bottom to the edge of the bed. Ask her to pull her knees back as far as she can while someone else pushes straight down just above the mothers pubic bone. Have the mother push as hard as she can during her next contraction.
DO NOT try to pull the baby out. This can hurt or kill the baby.
3. If the baby still does not come out, slide your hand along the babys neck until your fingers are touching the babys back. Push the babys upper shoulder forward at the same time the mother pushes with a contraction.
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:
What to do:
1. Deliver the first baby just as you would any single baby.
2. When you cut the first babys 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.
5. 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 babys neck
Sometimes the cord is wrapped around the babys neck. Usually you can just loosen the cord and slip it over the babys 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.
A breech birth is when the baby comes out buttocks first. 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.
What to do for a breech birth:
1. Help the mother keep from pushing until you see the babys bottom at the vagina. It is very important for the cervix to be fully open.
2. Have the mother get into a standing squat position.
Or if the mother is unable to squat, help move her bottom to the edge of the bed as soon as the babys legs or bottom come out.
3. Encourage her to push the rest of the babys body out slowly. The legs usually fall out but you may need to put your fingers inside the mother to bring them out.
4. Gently loosen the cord a little so it does not get pulled tight later. If the cord is still under the mothers pubic bone, move the cord to the side where the flesh is softer.
5. Wrap the babys 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 mothers pubic bone (not her abdomen). This is to keep the babys head tucked to its chest, not to push the baby out. Carefully guide the babys body down to deliver the top shoulder. Hold the baby by the hips or legs. Be careful! Pressure on the babys back or abdomen can injure its insides!
You may need to put your fingers inside the mother 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.
7. Carefully lift the baby to deliver the back shoulder.
8. The baby now needs to turn so it faces down towards the mothers bottom. You may wish to support its body with your arm, placing your finger in the babys mouth to help the head stay tucked. This is because when the babys chin is tucked to its chest, it passes more easily through the hip bones.
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!
10. Keep the babys head tucked in while you raise the body to deliver the face. Let the back of the head stay inside the mother.
11. The mother 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 damaged.
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 rags in an hour.
What to do:
1. Send for emergency help.
2. While you are waiting 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 mothers 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.
· If you have it, you can also give 10 mg oxytocin by injection in the buttock or thigh.
If the mother is too weak to deliver the placenta herself or if she is bleeding so heavily she becomes faint, you may need to help guide the placenta out. Only do this if you believe the womans life is in danger. First look for signs that the placenta has separated.
1. Mark the cord by tying a clean string around it about a hands width from the opening of the vagina.
2. Put one hand on the mothers abdomen just above her pubic bone. Wait until her womb feels hard and then push upward toward her head.
3. If the string you tied to the cord moves toward the mother, the placenta is probably still attached to the womb. Take the mother to the nearest hospital. If the string on the cord does not move, the placenta may be lying in the vagina and you can try to help guide it out.
4. With your other hand, hold the cut end of the cord (a dry cloth will help), and pull slowly and firmly. Do not pull hard. If you do not feel the placenta moving down, STOP.
5. When the placenta comes out, rub the top of the womb with one hand until it stays very hard. At the same time, push the bottom of the womb upward with your other hand.
6. Give fluids either in the vein (IV) or in the rectum.
If the placenta does not come out and the mother continues to bleed, take her to a health center or hospital.
If the bleeding starts after the placenta comes out:
· 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 mothers nipples. This will make the womb contract and stop bleeding.
Rolling the nipples can help the womb contract and stop bleeding.
· 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 ergometrine, 0.2 mg by mouth, or 0.5 mg by injection in her buttock or thigh. If she is still bleeding after 10 minutes, give the same amount of ergometrine again.
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.
Baby born too early or too small
A baby born before 9 months is born too early. A baby that weighs less than 2500 grams or 5 pounds is born too small. These babies need special care.
1. Dry the baby with a warm, clean cloth immediately after birth.
2. Put the naked baby against the mothers body. Cover the baby with many warm cloths or blankets. Make sure the head is covered and the room is warm.
3. Put the baby to the mothers breast. Small babies need to nurse at least every 2 hours.
4. DO NOT bathe the baby. It must stay warm.
Keep baby warm and dry.
Baby does not breathe
A baby must begin to breathe on its own within 2 to 3 minutes after the cord becomes white or the placenta separates from the womb wall. If the baby does not start to breathe, it can suffer serious brain damage or die.
What to do:
Clear the babys mouth and nose, and firmly rub its back and feet. If the baby still does not start to breathe, do rescue breathing:
1. Lay the baby on a hard surface, like a table or the floor
CARING FOR THE MOTHER JUST AFTER THE BIRTH
Encourage the mother to breastfeed her baby, which will help her to stop bleeding sooner. Also:
· Feel the top of the mothers womb. It should be hard and rounded, at about the level of her navel. If the womb feels soft, ask the mother to pass urine, then rub her womb until it gets hard. Keep checking the womb to see if it gets soft again. Check for bleeding. Teach the mother how to feel her womb and rub it if it gets soft.
· Look at the mothers vagina. If she has a long, deep tear, or a tear that will not stop bleeding, she should have it stitched by someone who knows how.
· Give her plenty to drink and eat if she is hungry.
Make sure the mother knows that breastfeeding is the best food for her baby. Keep the baby with the mother so it can suck the breast and stay warm. Encourage the mother to keep the baby warm and clean and to let it suckle as often as it likes.
Babies often have a little yellowish mucus coming from their eyes in the first weeks after birth. You can wash out the eyes with breast milk or cool, boiled water and a clean cloth. If the babys eyes get red, swollen, and have a lot of pus in them, the baby should be seen by a health worker.
Care of the cord
Keep the cord stump on the baby clean and dry. If possible, clean it with alcohol and a clean cloth with every diaper (nappy) change. It will turn black and fall off during the first week. You do not need to cover it with anything unless there are flies or dust Then you can use a very clean piece of gauze or cloth to cover it loosely.
If you notice redness or pus around the cord, the baby may have an infection. The baby should be seen by a health worker and be given antibiotics right away.
Tetanus of the newborn
Danger signs of tetanus in the newborn
What to do:
Take the baby to a health center or hospital right away. If the hospital is more than 2 hours away and you know how, first inject the baby with 100,000 units of benzylpenicillin.
IN THE FIRST WEEKS AFTER BIRTH
Caring for a new mother
Mothers need care after birth just as the baby does. People are often so busy looking after the baby that the mothers needs may be forgotten.
· To prevent infection the mother should not have sex or put anything in her vagina until her bleeding stops.
· She should get a lot of rest for at least 6 weeks.
· She should try to stay clean. It is good for her to wash and to keep her genitals very clean. While bathing, do not sit in water until 1 week after the birth.
· A new mother needs to eat more food than usual. She can eat any kind of food: fish, meat, beans, grains, vegetables, and fruit will all help her heal from the birth and have energy to be a good mother.
· She should drink plenty of fluids.
· If she is breastfeeding her baby and giving no other milk, the breastfeeding can protect her from getting pregnant again too soon.
· If she has a tear at the opening of her vagina, she should keep it clean. She can apply a hot, damp cloth and honey to the tear to help it feel better and to heal more quickly. If the tear causes burning, she can pour water over her genitals while she passes urine.
Any plant medicines used to help her genitals heal should be clean (boiled is best). Do not put plant medicines inside the vagina.
· She should start a family planning method soon, especially if she ever feeds her baby something other than breast milk. For her good health, she should start using a family planning method before she has sex again, or she could become pregnant too soon.
DANGER SIGNS IN THE FIRST FEW DAYS AFTER BIRTH
Bleeding that starts more than a day after the baby is born is usually caused by pieces of the placenta that have been left in the womb.
Danger signs of too much bleeding:
· soaks more than 2 pads or thick rags an hour in the first day after birth
· has a continuous small flow of blood
What to do:
1. Rub the top of her womb until it gets very hard and the bleeding stops. Have the baby suck on her breasts, or have someone roll her nipples.
2. Inject 0.5 mg of ergometrine in a large muscle, or give 0.2 mg of ergonovine by mouth every 6 hours for 4 to 7 days.
3. If the bleeding will not stop, get medical help. Continue to rub her womb as you take her to the hospital.
4. If she has signs of infection, give the same antibiotics as for womb infection described below.
Infection of the womb is very dangerous. It must be treated or the woman can become infertile or die.
Danger signs of womb infection:
· fever and chills
1. If these signs are present, give one of these combinations of medicines:
· 1st choice: amoxicillin, 1 g (1000 mg) by mouth, 3 times a day for 10 days, plus metronidazole, 500 mg by mouth 2 times a day for 10 days.
· 2nd choice: procaine penicillin, 800,000 Units by injection in the buttock 2 times a day for 7 days, or penicillin tablets, 400,000 Units (250 mg) by mouth 4 times a day for 7 days, plus chloramphenicol, 1 g by mouth the first time, then 500 mg 4 times a day for 7 days.
2. Encourage her to drink a lot of fluids. If she does not start to feel better by the next day, take her to the nearest hospital.
¨ If the mother complains that she does not feel well, watch her carefully for signs of infection.
LOSS OF A PREGNANCY (MISCARRIAGE)
A miscarriage is a pregnancy that ends by itself before the baby is fully developed. It is often the bodys way of ending a pregnancy when the unformed baby has a serious problem that would have kept it from developing well. Most miscarriages happen in the first 3 months of pregnancy. After a miscarriage, a woman can still become pregnant again and have a normal pregnancy and a healthy baby.
The signs of miscarriage are pain and bleeding. The bleeding and pain usually begin like normal monthly bleeding and then get heavier and stronger. There may also be some tissue or clots with the blood.
If the bleeding and pain continue for more than a few days, if the bleeding is much heavier than normal monthly bleeding, or if a woman gets a fever or has a bad-smelling fluid from her vagina, part of the pregnancy may still be inside the womb. This is called an incomplete miscarriage. It can lead to heavy blood loss, a dangerous infection, or even death. The woman should go to a health center or hospital where a trained health worker can empty the womb.
If a woman has strong, constant pain in her lower abdomen, she may have a pregnancy in the tube. This is very dangerous.
After a miscarriage a woman should rest and avoid heavy work or lifting for 2 weeks. She should not douche or wash inside her vagina. Also she should avoid sex until all bleeding stops because her womb is still open and could get infected.
Many women feel very sad after a miscarriage. Some do not. This is all normal. Some women may find it helpful to talk with other women who have lost a pregnancy.
A woman who wants children may feel very sad if she loses a pregnancy.
HELPING WOMEN WHO HAVE TROUBLE CARING FOR THEMSELVES AND THEIR BABIES
Some women are more likely to have difficult births and problems following birth, and their babies are more likely to be unhealthy. Mothers who are alone, very poor, very young, mentally slow, or who already have poorly nourished or sick children may have a harder time caring for themselves and their babies,
If someone takes special interest in these mothers, and helps them get the food, care, and companionship they need, it can often make a great difference in the well-being of both the mothers and their babies.
Do not wait for those in need to come to you. Go to them.
IF THE BABY DIES
Most women have healthy pregnancies and give birth to healthy babies. But sometimes, no matter what anyone does, the baby dies.
This is always a hard time for a mother. She feels great sadness and loss. At the same time, she has been through a pregnancy and birth and she needs to rest and get her strength back, just like a mother with a new baby.
The following advice may also help:
· Her breasts will probably be sore, especially around the 3rd day after the birth when her milk comes in. Cloths soaked in cool, clean water may reduce the soreness.
· not squeeze out either the first yellow milk (colostrum) or the regular breast milk. Removing milk will cause the body to make more.
· watch for signs of breast infection and treat if necessary.
· wait for at least 3 months before trying to get pregnant again. A womans body needs time to heal.
· start using a family planning method as soon as possible. She can become pregnant again too soon.
¨ A woman needs extra care and support when her baby dies.
For many women, this is a death like any death of someone she is close to, and she will need to mourn her loss. She needs special care, kindness, and support.
Showing your wife that you care about her can help her both physically and emotionally. Make sure she has help with her work. If you cannot do some of the work yourself, try to get someone else to help. Make sure she eats healthy foods and goes for prenatal care.
You can help your wife feel strong and safe during labor and childbirth by:
· making sure there is enough water and food in the house.
· bringing her midwife or health worker to the house to help with the birth.
· taking care of the other children.
If you stay with her during the birth, you can help by giving her both emotional and physical support. Encourage her and tell her she is doing well. Give her water to drink. Help her walk or squat during contractions or rub her back.
¨ Throughout pregnancy, childbirth and after, be alert for danger signs in the mother and baby. Seek help if you think there is a problem.
The first 6 weeks after birth are the most important time for a woman to feel strong and healthy again. During this time she needs a lot of healthy foods and plenty of rest. You can help her rest more by doing some of her work - like fetching water or fire wood, taking care of your other children, or preparing some of the meals. If you cannot help, try to find someone else who can.
If you take time to hold and care for your baby, your wife will have a chance to sleep and you can be close to your new child.
Do not have sex until the bleeding stops to prevent an infection in her womb.
To have healthy mothers and babies, it is best to wait at least 2 years between pregnancies. One of the most important ways you can help your family be more healthy is by using family planning. Visit the family planning clinic with your wife and decide together which method will work best Then share the responsibility for using it.
Throughout the world, millions of women die needlessly from problems during pregnancy and childbirth. Many of these deaths happen because a woman or her family wait too long to get help for emergencies.
Here is the story of a group of women who worked in their community to understand and solve some of these problems.
During the last rainy season, my friend Ekwefi was pregnant When it was time for her to give birth, her husband had gone away on a trip. Several wise women were there to help her. But the labor was too long and Ekwefi started bleeding. I said that we needed to take her to the health center. No one could decide what to do. Her husband was gone and he was the one who should decide. Soon after we realized that Ekwefi and the baby would not survive, they both died in front of us.
This made me very sad. Ekwefi was my friend, and we could not help her. I started talking with other women in my village. We had to do something about this problem. Ekwefi was not the first woman to die while she was giving birth. Many other women lost their babies during birth. Some women said this is how things are in our small village and we should accept it. But we said no, we can do something to solve this problem.:
We decided to have a meeting to learn more about the problem of women and babies dying during birth. During our meeting we decided to talk to the families with this problem. Six women in our group agreed to visit families where a woman had died from a difficult birth during the past two years, or where a woman was still recovering from one.
We learned several important things. Everyone agreed that the biggest problem was that women wait a very long time before they call a doctor or go to the health center. Sometimes a woman cannot ask for help without her husbands permission. Many times, like with my friend Ekwefi, the husband is not in the village when the woman needs to ask his permission to get help. The neighbors are afraid to give help, because they do not want the husband to be angry or offended. We also learned that most husbands do not know about the many risks women face during labor.
We decided to walk the 7 miles to the health center to talk to the midwife. We told her what we had learned and asked her to help us find ways to solve this problem. The midwife was very happy to help us. She talked to the head of our village and asked for a meeting with the elders. During the meeting, the midwife talked to the elders about the health risks of a long labor. She also told them what we had learned about women dying while giving birth in our village. The elders all agreed that this was a very serious problem for the whole village. They asked the midwife how this problem could be solved. The midwife told the elders that this was not just a problem in our village but in many villages in Nigeria. She suggested that the village pick 12 men and 12 women to go to a five-day training on reproductive health and family planning. These villagers would become reproductive health workers, and would work to teach and motivate the rest of the village.
After the training, the men who had gone realized that they had to be actively involved in solving this serious problem. They decided to work hard to teach the other men in the village about the risks of labor and how to help women in labor. They also decided to have a transportation committee to help women get to the health center when they needed it.
We all worked very hard to solve this health problem in our village. In the beginning, many people said that women often die giving birth and there was nothing we could do about it But we did not get discouraged. By working together with the women, the midwife, the elders, and the men of the community, we came up with a solution that works in our village. And the answer to our problem wasnt more money or a new technology. The answer was in our time and effort. All of us from the village of Lado encourage you to work together to improve the life and health of your community.
To learn more about thinking about and solving health problems, read the chapter on Solving Health Problems.
How to help save more childbearing womens lives
Most deaths and injuries from pregnancy and birth could be prevented through better nutrition, child spacing (with family planning), access to safe abortion, good care during pregnancy and birth, good transportation, and good blood services. To reduce these deaths:
· learn the danger signs during pregnancy, birth, and after birth.
· plan how to get help before it is needed.
· when problems arise, get help early.
· try to organize your community so that emergency transportation, money, and blood donations will be ready when difficult births happen.
· work with local leaders to build small houses near a hospital where women from remote areas can stay until it is time to give birth.
How health workers can help save womens lives
· Offer family planning services to prevent unsafe abortions and to help women avoid having births too close together.
· Offer STD treatment and prevention to all women and girls old enough to have children.
· Make tetanus vaccines available to all women, even if they are not pregnant.
· Learn how to detect problems during pregnancy, birth, and after birth.
· Refer women with problems in a pregnancy (now or in the past) to a health center that has emergency transportation.
· Teach birth attendants and midwives how to prevent infection and how to watch for and treat danger signs during pregnancy and birth.
· Encourage all women to breastfeed for at least 2 years.
· Have a medicine box that includes:
- oxytocin, ergometrine, and local plants to prevent and control severe bleeding after the birth.
- antibiotics to treat infection.
- equipment to do injections in the muscle (IM) and the vein (IV).
- medicines to treat toxemia.
- gloves or clean plastic bags.
- new razor blades.
- enema bag or can for rectal fluids.