Most women give birth normally and have a healthy baby. Occasionally things go wrong and the life of the woman and/or her baby is at risk. It is important to be aware of possible problems and watch for the warning signs so the woman can be referred for help before it becomes dangerous.

Long labour
It is not good for a woman to be in labour for more than 12 hours
(24 hours if it is her first baby) as both the woman and her baby can become exhausted. Long labours may be normal for a few women but are an important danger sign for others.

There are three main reasons for labour being slow:

1.the contractions are not strong enough. To make the contractions stronger you can try:

• giving the woman sips of a carbohydrate-based drink, e.g. rice-water, after every contraction to give her energy
• changing the woman’s position, especially getting her upright or walking around
• stimulating her nipples, for example by breastfeeding.

2.the woman’s bladder is full, slowing the contractions down. You can try:

• reminding the woman to pass urine every hour during labour. If that does not work;
• putting a catheter to drain the bladder, if you know how to.

the baby does not fit through the woman’s pelvis. This may be because the baby is not lying in a good position, or because the woman’s pelvis is too narrow. In both cases the woman needs to be sent urgently to a hospital which can do a caesarean section.

Prolonged pushing
It is not good for the woman to be trying to push her baby out for many hours. Good care during the pushing stage includes:

• encouraging the woman to wait to start pushing until she feels a very strong urge
• reminding her to empty her bladder
• examining the abdomen to make sure the baby is lying in the correct position for delivery - head first. (If the shoulder or back is coming first the woman must be referred immediately to hospital)
• asking her to push in the squatting position; this is more effective than trying to push in a lying or sitting position.

If the baby does not come out after 30 minutes of good pushing (60 minutes if first baby), the woman may need help. Do not delay, as the baby can quickly become short of oxygen at this stage. Also the woman may suffer serious damage to her vagina.

Not head first
Anything other than a baby’s head coming first through the woman’s
vagina can be a serious problem. If it is:

• an arm – the baby cannot be delivered in this position – refer to hospital immediately
• a cord – check the position of the baby. If it is lying sideways send the woman to hospital immediately. If the head is coming first the baby may be able to deliver this way but the baby will probably die before it is born.
• If you have a health centre close by where a caesarean section can be done, send immediately to the health centre.
• a foot or bottom – this means that the baby is in a breech position. If it is too late to get her to hospital, ask the woman to stand up for the delivery. Do not pull on the baby. Let the woman push the baby out into your hands.

Fever and fits
Both fits and fever are abnormal in labour. Both require urgent medical help. While you are transferring the woman:

• with fever, start antibiotics as soon as possible, according to local guidelines.
• with fits, make sure she lies on her left side (so that if she vomits she does not breathe it in).

Bleeding during labour
Bleeding during labour is a serious sign and the woman must be sent to hospital immediately.

Ruptured uterus
If the muscle of the uterus tears (ruptures) during labour both the woman’s and the baby’s life are in danger. The woman needs to be transferred immediately.

Warning signs to watch for are:

• the contractions suddenly become much weaker or stop completely
• the woman has low abdominal pain
• the woman is aware of ‘something having given way’ inside
• when examining the abdomen, the baby can be felt very clearly the
• woman goes into shock.

Trudy Stevens
Midwifery Research-Practitioner, Flat E5, 55-57 Boscombe Road
London W12 9HT, UK

The third stage of labour
Jilly Rosser advises on safe care immediately after birth

The third stage of labour is the time after the birth of the baby until the placenta has delivered and bleeding has stopped.
The third stage is a very important time; good care helps make sure that the mother does not bleed too heavily. Heavy bleeding is called a postpartum haemorrhage (PPH) and it is dangerous and frightening.

What to do
The cord When the baby is born, the cord is fat and blue. After a few minutes, the cord becomes thin and white and stops pulsing. Now the cord can be tied and cut. (In many places it is the custom to wait until the placenta is born before cutting the cord. When there is no problem with mother or baby, this custom is not harmful).

Delivery of the placenta Sometime after birth – it can be in the first few minutes, or not for an hour or two – the placenta separates from the wall of the uterus. When it separates a small gush of blood comes out of the vagina. Once the placenta has separated, it can be delivered. usually it is sufficient for the woman to get into an upright position – standing or kneeling or squatting – and the placenta will just slip out.
The best care when the placenta is delivering is ‘watchful waiting’. Do not interfere unless there is a problem.

If the placenta has not delivered after two hours

Do

• remind the woman to pass urine, to empty the bladder
• ask her to breastfeed her baby; this releases natural oxytocin into her blood
• give her a sweet drink, for energy

Do not

• pull on the cord
• poke the woman’s abdomen
• put your hand into her vagina.

If you have tried the remedies above and the placenta still does not deliver and you are in the community, you will need to arrange transport to a facility where the staff know how to do a manual removal of placenta and she can have a blood transfusion if she needs it. If there is no bleeding then it is not an emergency. By pulling and poking you could cause the placenta to partially separate, and then there will be heavy bleeding. Be sure you do not cause an emergency.

Danger signs
Heavy bleeding before the placenta has delivered This is an emergency. The woman will continue to bleed until the placenta is delivered. If you know how to, give an oxytocic drug (see box) and use controlled cord traction to deliver the placenta. If caring for women having babies is part of your work, and you do not know how to do these things, try to find someone to teach you. If you work outside a centre where there are doctors and midwives, learn how to do a manual removal of placenta. In a case of heavy bleeding you have no time to transfer the woman – you need to be able to give emergency care yourself.
Heavy bleeding after the placenta has delivered This is usually easier to deal with. You can encourage the woman to pass urine and to breastfeed the baby. Also try massaging the uterus by putting your hand on top of it (just below the navel) and rubbing with a circular movement. You will feel the uterus harden under your hand, and the bleeding will stop. If this doesn’t work, give an oxytocic drug (see box).

Risk
If a woman had a PPH after a previous birth, or she is giving birth to twins, then she is at higher risk in the third stage. It is safer for her to deliver with somebody who has oxytocic drugs and knows how to use them.
Jilly Rosser, 21 Sydenham Road
Cotham, Bristol BS6 5SJ, UK

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