Most births go well without intervention. The human body has been doing this without hospital equipment for the entirety of human history, and in most uncomplicated labors, the primary role of a birth attendant is to be present, keep things clean, and not interfere with a process that is working. This is important context. The panic that comes from attending an unexpected birth in a field setting is frequently more dangerous than the birth itself.
That said, complications exist and some of them kill quickly. Postpartum hemorrhage is the leading cause of maternal death worldwide. Umbilical cord prolapse, placental abruption, and newborn resuscitation failures all have field management options that require prior knowledge to execute. This post covers what to do in an unplanned delivery — normal management, and the complications that change the protocol.
This post is not medical advice and is not a substitute for qualified medical or midwifery training. It is field-level knowledge for a scenario where no qualified care is available. If care is available, access it.
RECOGNIZING ACTIVE LABOR
Labor is the process of uterine contractions dilating the cervix and eventually delivering the baby. Not all contractions are active labor — early labor and Braxton Hicks contractions can feel similar. Signs that delivery is imminent:
- Contractions are 2-3 minutes apart, lasting 60-90 seconds, and have been progressively intensifying
- The woman reports an overwhelming urge to push or bear down — this indicates the baby is in the birth canal
- The perineum (area between vagina and anus) is bulging or the baby’s head is visible (crowning)
If the head is crowning, delivery is minutes away. Stop moving the patient. Prepare.
WHAT YOU NEED
Ideally: Clean hands (washed thoroughly with soap and water), clean gloves, clean towels or cloths for drying the baby, a clean surface for the newborn, a clean cutting instrument, cord ties or clamps, a clean blanket for warmth.
In an austere environment: The minimum is clean hands and something clean to receive the baby. Sterilize what you can with heat or alcohol. Work on the cleanest available surface.
NORMAL DELIVERY — MANAGEMENT
Step 1 — Position the mother. Semi-reclined (propped at 45 degrees) or hands and knees are both effective and comfortable for most women. Flat on the back is the least optimal position — it compresses the major vessels supplying the uterus and makes pushing less effective. Support whatever position the woman finds comfortable.
Step 2 — As the head crowns. Place a clean hand gently against the emerging head — not to slow it forcibly, but to provide gentle counter-pressure and prevent explosive delivery that can cause perineal tearing. Ask the mother to breathe through contractions rather than pushing hard at this point — slow, controlled delivery of the head is the goal. Do not pull on the head.
Step 3 — Check for cord around the neck. Once the head is delivered, feel around the neck for the umbilical cord. If the cord is loosely looped, slip it over the baby’s head. If the cord is tightly wrapped and cannot be slipped over, the cord must be double-clamped and cut before the body delivers — this is an emergency requiring quick action.
Step 4 — Deliver the body. The body typically follows the head with the next contraction. The baby will rotate spontaneously to deliver the shoulders — do not rush this rotation. Support the head but do not pull. As the shoulders emerge, support the body — a wet newborn is slippery and heavy for its size.
Step 5 — Clear the airway. Hold the newborn with the head slightly lower than the body to allow fluid to drain from the airway by gravity. Wipe the mouth and nose with a clean cloth. A bulb syringe is helpful but not required in a vigorous, crying newborn.
Step 6 — Dry and warm the baby immediately. Hypothermia is the primary threat to a newborn in a field setting. Dry vigorously with a clean cloth — the drying itself stimulates breathing. Wrap in a warm cloth or blanket and place against the mother’s bare skin (skin-to-skin). Cover both with a blanket.
Step 7 — Assess the newborn. A normal newborn: cries within seconds of birth, has good muscle tone (not floppy), turns pink within a minute of delivery (hands and feet may remain bluish for several minutes — this is normal). A vigorous cry is the most reassuring sign. See Newborn Resuscitation below if the baby is not vigorous.
Step 8 — Cord management. The cord does not need to be cut immediately. Delayed cord clamping (waiting 1-3 minutes or until the cord stops pulsating) is beneficial for the newborn. When ready to cut: tie or clamp the cord firmly at two points approximately 2 inches and 4 inches from the baby’s navel. Cut between the clamps with a clean instrument. The cord is not painful to cut — it has no nerve endings.
Step 9 — Deliver the placenta. The placenta delivers within 5-30 minutes of the baby. Do not pull on the cord to hurry it. Signs that the placenta is ready to deliver: a gush of blood, the cord lengthens, and the uterus changes shape (rises slightly in the abdomen). With the next contraction, the mother can push the placenta out. Examine the placenta after delivery — it should be intact. A retained piece of placenta causes ongoing hemorrhage and infection.
Step 10 — Uterine massage after placental delivery. Place a hand on the abdomen and feel for the uterus — it should be firm and contracted. If the uterus is soft or boggy, massage firmly until it contracts. Uterine contraction is the primary mechanism preventing postpartum hemorrhage.
COMPLICATIONS
POSTPARTUM HEMORRHAGE (PPH)
The most common cause of maternal death in birth. Defined as blood loss exceeding 500mL after vaginal delivery. In the field, estimate: soaking more than one large pad or towel in 15 minutes, or any bleeding that does not slow after uterine massage and placental delivery.
Treatment:
- Uterine massage — firm, continuous massage through the abdominal wall until the uterus contracts and bleeding slows. This is uncomfortable. It is necessary.
- Breastfeeding or nipple stimulation — triggers oxytocin release, which causes uterine contraction
- Bimanual compression — one hand on the abdomen pressing down on the uterus, two fingers of the other hand inside the vagina pressing upward against the uterine body — compresses the uterus between the two hands. This requires training to execute correctly.
- Oral misoprostol (200-800mcg sublingual or rectal) — a prostaglandin that causes uterine contraction. Available by prescription. In austere settings, misoprostol is the most important single pharmaceutical for birth preparedness. Worth discussing with a physician or midwife if birth is anticipated in a setting without hospital access.
- Treat shock — see Shock — Recognition & Response
CORD PROLAPSE
The umbilical cord slips through the cervix ahead of the baby. The baby’s head or body then compresses the cord, cutting off fetal blood supply. This is immediately life-threatening to the baby and requires delivery within minutes.
Signs: cord visible at the vaginal opening, sudden fetal distress, baby not progressing after active labor.
Field management: the only intervention is to prevent cord compression while moving to deliver the baby as quickly as possible. If possible: position the mother on hands and knees (this uses gravity to shift the baby off the cord), and gently push the presenting part (head or body) off the cord with a gloved hand inside the vagina — do not pull the cord. Maintain this pressure until delivery is completed.
SHOULDER DYSTOCIA
The baby’s head delivers but the shoulder becomes stuck behind the mother’s pubic bone. Signs: the head delivers and then retracts back against the perineum (“turtle sign”), body does not follow.
Field management: McRoberts maneuver — hyperflexion of the mother’s thighs against her abdomen (pull knees toward her chest and hold there). Suprapubic pressure — a second person presses firmly on the mother’s abdomen just above the pubic bone, pressing in the direction that would move the baby’s front shoulder downward. Do not pull forcibly on the baby’s head — this causes injury. These maneuvers free the shoulder in the majority of cases.
NEWBORN RESUSCITATION
A newborn who is not vigorous — not crying, floppy, pale or blue, not breathing — requires immediate intervention.
Step 1 — Stimulate. Dry vigorously, flick the soles of the feet firmly, rub the back briskly. Most depressed newborns respond to aggressive stimulation and begin crying within 30-60 seconds.
Step 2 — Airway. Position the head in a neutral sniffing position. Clear the mouth and nose of visible secretions with a cloth or bulb syringe.
Step 3 — Breathing. If the baby is not breathing after 30-60 seconds of stimulation: begin positive pressure ventilation. In a hospital setting, this uses a bag-valve-mask. In the field: mouth-to-mouth-and-nose ventilation with very small puffs (only enough to see the chest rise — newborn lungs are tiny). Rate of 40-60 breaths per minute.
Step 4 — Chest compressions. If there is no detectable heartbeat after 30 seconds of ventilation: begin chest compressions. Two thumbs on the lower third of the sternum, fingers wrapped around the back. Compress approximately one-third of the chest depth. Rate 90 compressions to 30 breaths (3:1 ratio). Reassess every 2 minutes.
A newborn who does not respond to these measures in a field setting has a guarded prognosis. Continue efforts until the newborn begins breathing and has a detectable heartbeat, or until it is clear that resuscitation cannot succeed.
WHAT TO STOCK IF BIRTH IS ANTICIPATED
- Bulb syringe (for newborn airway)
- Cord clamps or clean cord ties (several)
- Clean scissors or a blade (for cord cutting) and alcohol for sterilization
- Clean towels and blankets (several — newborns wet everything)
- Nitrile gloves (multiple pairs)
- Oral misoprostol (discuss with physician or midwife) for postpartum hemorrhage
- A birth kit (available commercially through midwifery suppliers — contains all of the above in sterile packaging)
Training: A hands-on birth skills course or wilderness first responder course with obstetric content is the minimum for anyone who may be in a birth-attendant role in a grid-down scenario. Reading this post prepares you intellectually. Hands-on practice prepares you practically.
Cross-reference: Shock — Recognition & Response | Infection Management | Hypothermia | Medications — When SHTF