CHILDBIRTH

In concluded pregnancies, the majority of childbirths are normal, but in some cases, without warning, problems may occur that put the life of the mother and child in danger. In these cases the patient should be disembarked in time to be hospitalised.

The child is normally born 40 weeks after the mother has conceived. Occasionally, for various reasons, the birth can be premature. If the child is born on board three or four months prematurely, it may not survive (see MISCARRIAGE).

The appropriate place for childbirth is in the hospital. If, for whatever reason, this is not possible and childbirth begins, the vessel should head for the nearest port and the following preparations should be implemented.

Preparations for childbirth

An appropriate cabin should be made available. If possible, it should be large enough to allow access from the feet and both sides of the bunk. If the infirmary is to be used, all other patients should be moved to another part of the ship. If the patient cannot be moved or the infirmary has been used for a patient with an infectious disease, the expectant mother should be moved to another cabin as clean and hygienic as possible. It should be comfortable and at a temperature of 21º C. A plastic or waterproof sheet should be used to cover the bunk and it should be placed directly below the sheet to protect the mattress

Hot water, soap, cloths and towels are needed, along with a bedpan (DRAWER 15, medicine kit A), a container for the placenta (DRAWER 12 medicine kit A), four 25 cm long strips of tape, surgical scissors (DRAWER 12, medicine kit A), sterile gauzes (DRAWER 14, medicine kit A), two small sterile dressings (DRAWER 14, medicine kit A), a 5c.c. syringe and needle (DRAWER 12, medicine kit A), 0.9% physiological saline serum (DRAWER 13, medicine kit A) and a mechanical suction instrument to clear obstacles from the respiratory routes (OTHER MATERIAL NOT INCLUDED IN DRAWERS, MEDICAL KIT A). All instruments along with the tape should be sterilised by boiling for at least 20 minutes. In addition, there should be a soft, clean blanket prepared and ready to use to wrap around the baby, an appropriate box equipped with clean sheets to serve as a cot and a clean nightgown and sheets for the mother after the birth.

The person or people assisting the birth should be healthy and not suffer from coughs, colds, infectious illnesses or skin disease. Before touching either mother or child the assistant should scrub and clean their hands, wrists and arms thoroughly with soap and water (nailbrush, DRAWER 12, medicine kit A), wear sterile rubber gloves (DRAWER 14, medicine kit A) (as indicated in Chapter 7.1, INJURIES) and clean clothes.

Signs and symptoms of the start of childbirth:

1. Labour pains begin approximately every two minutes. In general; they start with back pains or contractions in the lower part of the abdomen. During these symptoms, the mother feels the need to push to force the foetus out. Ask for MEDICAL ADVICE VIA RADIO and prepare evacuation to the nearest port.
2. The mother should be encouraged to clear the intestine and bladder before the birth starts and clean these areas thoroughly.
3. The labour pains become stronger and more frequent during a variable number of hours until they take place approximately every minute. There will probably then be a «sample», that contains a small quantity of blood and mucus that descends from the vagina. The birth process has begun.
4. Breaking of the water bag. Generally, in a short space of time, though sometimes only after several hours, the womb's water bag in which the baby is wrapped will break and a large quantity (from 250 to 500 ml) of thick liquid will exit the vagina.
5. The mother will cry out constantly and realise the baby is coming. The drop and exit of the baby can last between 30 minutes to several hours.

How to carry out the childbirth

1. The bed and cabin should already be prepared, and the person who is going to assist (see above) should also be ready. Ask the mother to undress from the waist down and lie face up with knees bent and thighs well apart.
2. Inspect the vaginal canal to see if the head appears in the moment of contraction. If it does, it is most probable that the moment of birth is very near (figure 10-1).
3. Ask the mother not to push or squeeze with the stomach, but to breathe deeply. The premature expulsion or too rapid exit of the baby's head could tear the vagina.
4. If the amniotic bag has not broken and still covers the baby's head, break it so that the liquid is released. If no blunt instrument is available, use the fingers to break the bag. Siguiente, pull away the membranes and clear them from the baby's face so that it can breathe.
   
   
   
   Picture 10-1: View of the baby's head when birth has begun.
   
   
5. When the baby's head appears, hold it with both hands (figure 10-2), without trying to slow down or speed up the tempo of the birth by pulling or pushing.
   
   
   Picture 10-2: Hold the baby's head.
   
   
6. Check the position of the umbilical cord; if it is wrapped around the baby's neck, pull it gently over the head (figure 10-3).
   
   
   
   Picture 10-3: Pull the cord.
   
   
7. Continue holding the baby's head while it exits. The shoulders usually come out with the second contraction and it is therefore necessary to encourage the mother to breathe deeply four times and push with all her force. When the shoulders appear, gently lead the head downward to allow the upper one to free itself. (figure 10-4).
   
   
   Picture 10-4: Exit of the upper shoulder.
   
   
8. With the following contraction, the opposite movement should be made to facilitate the exit of the lower shoulder (figure 10-5). Never force the baby in any direction.
   
   
   
   Picture 10-5: Exit of the lower shoulder.
   
   
9. Encourage the mother to push forcefully again so that the rest of the body can exit. The newborn is very slippery and must be held firmly, though gently; the best way is to hold the head with one hand, and the buttocks or feet with the other (figure 10-6).
   
   
   Picture 10-6: Holding the newly born.
   
   
10. Hold the baby upside down so that the mucus is cleared from the mouth and nose (figure 10-7). And clean them with a clean cloth or gauze. The baby normally begins to breathe spontaneously.
    
    
    Picture 10-7: Hold upside down.
    
    

Special considerations for the baby

1. If the baby does not start breathing spontaneously, help it by gently rubbing it's back or the soles of his feet until it begins to cry.
2. If this has no response, introduce your fingers into the mouth to remove any mucus or use the mechanical suction to unblock the respiratory tract (OTHER MATERIAL NOT INCLUDED IN DRAWERS, Medical kit A). If, despite all this, there is no improvement, begin mouth to mouth-nose resuscitation and cardiac massage (see picture and figures 10-8 and 10-9).
   
   
   
   Picture 10-8: Mouth to mouth-nose resuscitation.
   
   
   
   Picture 10-9: Cardiac massage.
   
   
   
   NEWBORN CPR
   1 BREATH EVERY 3 SECONDS
   + 5 COMPRESSIONS FOR EACH BREATH
   (Depress the sternum 1,5-2,5 cm with each compression)
   
3. When the baby is breathing, clean the eyes with a sterile swab soaked with 0.9% physiological saline extracted from the vial using a syringe.
4. When the umbilical cord is still, tie two strips of tape around the cord; one strip should be tied 5 cm from the baby's abdomen, and the other 2.5 cm further away; cut between the two knots with the surgical scissors (see figure 10-10) and cover the part attached to the baby with a sterile dressing.
   
   
   
   Picture 10-10: Tying and cutting the umbilical cord.
   
   
5. Dry the baby off quickly so that it does not catch a cold and place it, completely wrapped up in a blanket on top of the mother, leaving only the face exposed (figure 10-11). It is best to place the baby on her breast, as this will help in the expulsion of the placenta.
   
   
   
   Picture 10-11: Mother and Child

Special considerations for the mother

1. The contractions will begin again after the birth of the baby. These contractions are to expel the remaining placenta. Do not pull the umbilical cord nor press on the mother's stomach. The placenta could take 30 minutes to be expelled after the birth; therefore, the mother should be sent to a hospital as soon as possible, without it being necessary to wait for the expulsion to begin.
2. On the other hand, if there are signs that the expulsion of the placenta has begun (increase in the length of the umbilical cord and blood seeping from the vagina), tell the mother to push strongly while pressing gently on the abdomen.
3. When the placenta appears (figure 10-12) (with a fatty, flat mass appearance some 15-20 cm in diameter, with the cord attached to it's centre), the haemorrhage can be controlled by massaging the uterus. To do this, place one hand on the lower part of the abdomen and begin to massage firmly but gently. You will feel the uterus begin to harden as a result of the massage. This action should be repeated every 5 minutes for an hour, or until medical assistance is available.
   
   
   
   Picture 10-12: Expulsion of the placenta.
   
   
4. Save the placenta, the membrane and other material expelled by the mother in a plastic bag and place it in a refrigerator to send to the hospital with the mother and child.
5. Clean the orifice of the vagina with a damp towel and place a clean cloth or compressor over the top.
6. Wash the mother and dress her in a clean night gown, then make the bed again with clean sheets. Give her a hot drink and if, it has not already been done, allow her to hold the baby to her breast for a while.

Warning: Do not attempt the birth without the assistance of a doctor if the baby's feet, arms, shoulders or buttocks appear first instead of the head. If this is the case, it is imperative that the mother be moved to a hospital urgently.