doi:10.1016/j.jmwh.2004.04.030

FROM THE AMERICAN COLLEGE OF NURSE-MIDWIVES

Giving Birth “In Place”: A Guide to Emergency

Preparedness for Childbirth

Deanne Williams, CNM, MSN

EDITOR’S NOTE

What can midwives do to help women who are at risk of giving

birth without a trained attendant? The following document from the

American College of Nurse-Midwives is available on the ACNM

web site at http://www.midwife.org/focus/inplace.cfm, and although

written for families in developed countries, the content can be

adapted to any setting. This document can be used as a patient

handout or it can be used by health care providers who are not

experienced in attending births.

Although most women do not go into labor during emer-

gencies and most of those who do can get to a hospital or

birth center, recent events have raised concerns about what

to do if travel is not possible. Being prepared can help. The

information here includes a list of supplies (Table 1) and

directions for managing a normal labor and delivery while

taking shelter in place.

This is not a “do-it-yourself”guide for a planned home

birth, nor is it all the information you need for every emer-

gency. It is not meant to replace the knowledge and skills of a

doctor or midwife. The information is a basic guide for

parents-to-be who want to be ready in case they have to give

birth before they can get to a hospital or birth center.

CALL FOR HELP

If you think you are in labor, try to get to a hospital, birth

center, or clinic. If you are alone or travel seems unwise,

call the emergency number in your community and ask for

help. After you have called for help, keep your front door

unlocked so that rescue workers can get in if you are unable

to come to the door. Call a neighbor to come and help the

family. If the phones are working, keep talking to emer-

gency services or your health care provider who can “talk

you through” a labor and birth.

If your labor is going fast and birth seems near, stay at

home and have your baby in a safe place rather than in the

back seat of the car. Fast labors are usually very normal,

and the mothers and babies can both do well. Slow labors

will give you time to get to a hospital or birth center, or for

a health care provider to get to you. Get out your supply kit

and put the supplies where you can easily reach them.

As the helper, your job is to

Keep mom comfortable. It is good for her to walk, take a

shower, get a massage, and move even if she is in bed.

Be sure she drinks lots of ﬂuids. Water, tea, and juice are

the best.

Be sure she goes to the bathroom every hour.

Say and do things that create a calm feeling, even if you

are very nervous.

Wear gloves if you are going to be touching blood.

Wash your hands or gloves often.

Do not let pets into the labor and birth room.

Talk to mom about the sounds of childbirth. Making

groaning or crying noise during labor is ok and can help

the mom-to-be. It can scare the helpers. So mom has to

try to not scream and lose control, and the helpers have

to let mom make the noise that helps her cope.

Decide how to help other members of the family. Will

they be present for the birth? What do they need to

feel safe?

PREPARE THE BED

To keep the mattress from getting wet, cover it and the

sheets with a shower curtain and then cover the shower

curtain with another clean sheet, plastic-backed under pads

and lots of pillows for comfort. The mother may want to

spend a lot of time in bed, or she may prefer to be on her

feet or in a chair. Whatever feels best is okay.

WHEN THE BABY’S HEAD IS COMING FIRST

If you know your baby has been head down during the last

weeks of pregnancy, chances are good that the baby will be

head ﬁrst at birth. This is the most common position for a

baby. First labors can last for 12 hours or more, whereas the

next babies can come much faster.

The Urge to Push

The longest part of labor is the time it takes for the cervix

to open wide enough for the baby to pass into the birth

canal or vagina (ﬁrst stage). You can tell the cervix has

Address correspondence to Deanne Williams, CNM, MSN, Executive Direc-

tor, ACNM, 8403 Colesville Rd., Suite 1550, Silver Spring, MD 20910-6374.

E-mail: [email protected]

48 Volume 49, No. 4, Suppl. 1, July/August 2004

Issued by Elsevier Inc.

opened all the way (fully dilated) when the mother has a

very strong need to push (second stage). She cannot hold

back that urge and may make sounds like she is going to the

bathroom. Once she starts pushing, the baby can be born in

a few minutes or a couple of hours. As birth gets closer, the

area around the vagina begins to bulge out until the top of

the baby’s head can be seen at the vaginal opening. The

mother should be encouraged to push the baby’s head out

gently in any position that is comfortable for her. She does

not have to lie on her back in bed, but you will feel safer if

she is lying down or squatting so the baby can slip gently

onto a soft surface.

Put on your gloves and get in a place where you can see

the baby come out. Remind mom to push gently even when

she wants to push hard. As the baby comes out, mom will

feel a lot of burning around the vagina and this is when she

may make a lot of noise. After the head is born, look and

feel with your ﬁngers to ﬁnd out if the cord is around the

baby’s neck. If you ﬁnd a cord around the neck, this is not

an emergency! Gently lift the cord over the baby’s head, or

loosen it so there is room for the body to slip through the

loop of cord.

The baby’s head will turn to one side and with the next

contraction the mother should push to deliver the body. If

the body does not come out, push on the side of the baby’s

head to move the head toward the mother’s back. The

shoulder will be born. The rest of the body slips out easily

followed by a lot of blood-colored water.

If the Head Is Born but the Body Does Not Come Out After

Three Pushes

The mom must lie down on her back, put two pillows under

her bottom, bring her knees up to her chest, grab her knees,

and push hard with each contraction. After the baby is born,

place her or him on the mother’s chest and tummy, skin to

skin, and cover both with towels. If the baby is not crying,

rub her back ﬁrmly. If she still does not cry, lay her down

so that she is looking up at the ceiling, tilt her head back to

straighten her airway, and keep rubbing. Not every baby

has to cry, but this is the best way to be sure the baby is

getting the air she needs.

If the Baby Is Gagging on Fluids in Her Mouth and Turning

Blue

Use the baby blanket to wipe the ﬂuids out of her mouth

and nose. If this does not help, use the bulb syringe to help

clear things out. Just squeeze the bulb, place the tip in the

nose or mouth, and release the squeeze. This will suck ﬂuid

into the bulb. Move the bulb away from the baby and

squeeze again to empty the bulb. Repeat until the ﬂuid is

removed.

If the baby is still not breathing, follow the CPR

directions.

THE UMBILICAL CORD

There is no rush to cut the cord. All you have to do is keep

the baby close to the mom so the cord is not pulled tight. If

you pick the cord up between your ﬁngers, you can feel the

baby’s pulse. Within about 10 minutes the pulse will stop.

At that time you can tie and cut the cord. Remember the

cord is connected to the placenta (afterbirth) which is still

inside the mother.

THE BABY

At the time of birth, most babies are blue or dusky. Some

cry right away and others do not. Do not spank the baby,

but rub up and down her back until you know she is taking

deep breaths. Once the baby starts to cry, her color will be

more like her mom, but her hands and feet will still be blue.

Now is the time to keep the baby warm. Remove the wet

towel that is over the baby and put another dry towel and

Table 1. Supplies for Giving Birth “In Place”

The following list is not a “do-it-yourself” list of supplies for a planned

home birth, nor is it all the information you need for every

emergency.

The following supplies can be found at most drugstores, cost about

$70, and should be kept in a waterproof bag away from children

and pets. Keep them in a tote bag in case you leave home.

1. Baby size bulb syringe (made of soft plastic, often called an ear

syringe; should not be a nasal syringe as the plastic tip does

not ﬁt into a baby-sized nose).

2. A bag of large-sized under pads with plastic backing to protect

sheets from messy ﬂuids

3. Small bottle of isopropyl alcohol

4. Package of large cotton balls

5. Box of disposable plastic or latex gloves

6. White shoe laces (to tie umbilical cord)

7. Sharp scissors (to cut umbilical cord)

8. Twelve large sanitary pads

9. Chemical cold pack (the kind you squeeze to get it cold)

10. Hot water bottle (to help keep baby warm)

11. Six disposable diapers

12. Pain pills such as Tylenol or Advil

13. Small bar of antibacterial soap or liquid antibacterial hand

sanitizer

Additional items you will use

1. Shower curtain

2. Four cotton baby blankets

3. Newborn cap

4. Medium-sized mixing bowl

5. Four towels

6. Wash cloth

7. Blankets to keep mom warm

8. Pillows

9. Five large trash bags for dirty laundry

10. Two medium-sized trash bags for the placenta

11. Instructions for CPR for adults and babies

12. Emergency contact information

If you think you are going to have to give birth at home, put the

scissors and shoe laces in a pan of boiling water for 20 minutes.

When done, pour off the water but do not touch the items until

needed. If there is no way to boil water, wash the scissors and laces

with soap and water and soak them in alcohol during the labor.

Journal of Midwifery & Women’s Health • www.jmwh.org 49

blanket over the mother and baby. Put a hat on the baby.

The mother can help keep the baby warm with her body

heat.

Put the baby to breast. Even if you did not plan to

breastfeed, one of the safest things you can do for mom and

baby is put the baby to breast. A breastfeeding baby helps

keep the mother from bleeding too much and gets the food

it needs right away. If the cord is too short to allow the baby

to reach the breast, it is ok to wait until you cut the cord.

CUTTING THE CORD

There are no nerve endings in the cord so it does not hurt

either the baby or the mother when it is cut. It is very

slippery so take your time because there is no rush. Wash

your hands, put on gloves and then get the container with

the scissors and shoelace. Tie one of the laces around the

cord very tightly with a double knot about 3 inches from the

baby’s tummy. The baby will cry when she is uncovered

because she is cold, not because it hurts. Tie the other

shoelace around the cord about 2 inches from the ﬁrst knot.

Pick up the scissors by the handle without touching the

blades. Cut between the knots you have tied. It is rubbery

and tough to cut especially if you have dull scissors. After

it is cut, place the end of the cord that is still connected to

the mother’s placenta into the mixing bowl. Cover the baby

again to keep her warm.

THE PLACENTA OR AFTERBIRTH (THIRD STAGE)

The placenta looks like a big piece of raw meat with a shiny

ﬁlm on one side. On the other side it has membranes that

are attached to the placenta (the membranes look like skin

that has been peeled off). When the placenta is ready to

come, you will see a gush of blood from the vagina and the

cord will get a little longer. Put the bowl close to the

mother’s vagina and put more waterproof pads under her

bottom. Ask the mother to sit up and push out the placenta

into the bowl.

There will be a lot of blood and water coming after the

placenta. Firmly rub the mother’s stomach below her belly

button until most of the bleeding stops. This will hurt but

needs to be done. The heaviest bleeding should stop in a

minute and then the bleeding will be more like a heavy

period. If the bleeding increases again, very ﬁrmly rub the

mother’s lower belly until the bleeding slows. When it is

ﬁrm, you will be able to feel the uterus (womb), which is

the size of a large grapefruit, in the lower belly. A ﬁrm

uterus is a good thing because it will stop the mom from

bleeding too much (see Figure 1).

Mom’s bottom and her uterus may be sore. You may see

places where the mother’s skin has torn around her vagina.

Most of these tears will heal without any problems. Mom

will feel better when you put an ice pack on her bottom

where the baby came out and then put the sanitary pad on

top of the ice pack. She may want to take a couple of pain

pills at this time.

Put the placenta in a medium-sized trash bag and wipe

off any blood on the outside of the bag. Put this bag into a

second trash bag. Take the placenta with you to the hospital

or birth center. If you cannot leave the house for more than

4 hours, put the bagged placenta in a container with a lid

and put it in the freezer.

CLEAN UP

After the mother has delivered the placenta and the bleed-

ing has slowed down, give her a drink of juice, soup, or

milk and something to eat like crackers and cheese or a

peanut butter and jelly sandwich. Put on gloves to clean up

the bed. Roll up the sheet and pads inside the shower

curtain and put in a large plastic bag. Have clean under pads

ready to cover the sheets and a sanitary pad for the mother.

The dirty sheets and towels can be washed in cold water

with bleach or ammonia added. Wear gloves when touching

items that are bloody. Put a diaper on the baby or you will

be sorry!

BREASTFEEDING

It is important for the mother to breastfeed the baby in the

ﬁrst hour after birth and at least every 2 hours until her milk

comes in.

● Breastfeeding will keep the uterus ﬁrm and decrease

bleeding.

● Colostrum, the liquid that is in the breasts right after birth

until the milk comes in, will give the baby all of the food

she needs and it will help prevent infection.

● Even if the emergency situation continues for days,

weeks, or months, there will always be a ready supply of

safe and perfect food for the baby.

Getting Started With Breastfeeding

A newborn will nurse best in the ﬁrst hour after birth when

she is awake and alert. The mother may be more comfort-

able if she lies on her side with pillows under her head. The

mother and baby should be face-to-face and belly-to-belly.

Figure 1. After the placenta is delivered rub the uterus to control bleeding.

50 Volume 49, No. 4, Suppl. 1, July/August 2004

The baby will also nurse better if they are skin-to-skin (see

Figure 2).

The mother should place her nipple and breast against the

baby’s lips. The baby will lick and try to nurse. The mother

needs to help out by placing her nipple into the baby’s open

mouth. It may take a few tries before the baby can start

sucking. If the baby is sleepy, rub her belly and back ﬁrmly

to wake her up. If the baby is too sleepy, try uncovering her

for a short time and rubbing the mother’s nipple against the

baby’s lips. If the mother gets tired, take short breaks and

start again. Once the baby nurses for the ﬁrst time it gets

easier.

If the baby sucks a few times and then lets go and the

mom has large breasts, mom may need to help the baby

breathe by using her ﬁnger to hold some breast tissue away

from the baby’s nose.

What to Avoid

● Don’t use a paciﬁer or a bottle to start the baby sucking.

It confuses some babies because they do not suck the

same on the mother’s breast and a bottle or paciﬁer.

● Do not separate the mother and baby for very long. The

more they stay together, including when they sleep, the

sooner breastfeeding will be well established.

CARE OF THE MOTHER

If you still cannot get to the hospital or birth center to be

checked, the mother should go to the bathroom within

an hour after the baby is born.

If the room is cold, you can use the hot water bottle to

help keep the baby warm. Just wrap the warm bottle

in a blanket and place it next to the baby’s back.

After birth in a hospital, women are usually offered

Tylenol or Advil for pain every 3 to 4 hours as

needed. This would be a good choice at home if the

mother does not have an allergy to this medication.

When a new mother gets out of bed for the ﬁrst time, she

may feel dizzy. It is important to have her leave the

baby on the center of the bed and get up slowly:

● Sit up on the side of the bed to see how she feels.

● Have an adult take her to the bathroom and wait to be

sure that she is not feeling faint.

● If she says she is going to faint, believe her and have her

lie down on the ﬂoor. Do not attempt to walk her back to

bed. You have about 10 seconds to get her down on the

ﬂoor before she passes out and bangs her head on the way

down! Once she is down ﬂat, she will wake up and feel

better. Just wait a few minutes and then carefully help her

back to bed.

In a couple of hours the mom may want to take a shower.

Be sure she has had something to eat and is not dizzy when

she gets up. It is good to have someone close by because

dizziness can return quickly.

WHAT TO DO FOR THE MOTHER AND BABY IN THE FIRST 2

to 3 DAYS

If you still are unable to get professional health care for

several days, you can take care of yourself and your

baby during this time by remembering the basic

needs: eat, drink ﬂuids, rest, and feed and care for the

baby.

Keep someone with you as a helper so you can rest most

of the time. The helper should see that you always

have plenty of ﬂuids at your bedside and something to

eat each time you breastfeed the baby.

Keep ice on the vagina where the baby came out for the

ﬁrst 24 hours. To keep the area extra clean, pour

warm water over the vagina every time you go to the

bathroom.

Check the uterus for ﬁrmness every few hours until the

gushes of blood and/or clots stop and the baby is

breastfeeding every 2 to 3 hours.

Change the baby’s diaper every few hours. The baby’s

ﬁrst bowel movements will be black and sticky

(meconium), so be sure that the diaper is snug! The

baby needs to wet at least once every 24 hours until

the mother’s milk comes in. After the milk is in, the

baby will wet six to eight diapers a day. If the baby is

not wetting, nurse the baby more often.

Each time you change the diaper, clean off the umbilical

cord with cotton balls soaked with alcohol. The diaper

should be placed below the umbilical cord to help

keep it clean and dry (it turns dark as it dries). If the

cord has a bad smell, a sign of infection, clean it with

alcohol until the smell is gone.

Figure 2. Breastfeeding: face-to-face and belly-to-belly.

Journal of Midwifery & Women’s Health • www.jmwh.org 51

WHAT IF THE BABY IS COMING BOTTOM FIRST?

A few babies are born bottom ﬁrst. You will probably not

know this is the case until mom pushes and you see a

bottom or feet and not a head coming out. At that time you

must

Bring the mom’s bottom to the edge of the bed and have

her legs pulled up to her chest.

Prepare a soft landing spot for the baby on the ﬂoor.

Let the baby’s body (arms too) come out without

touching the baby. You will be looking at the baby’s

back. Yes, you have to let her little bottom hang down

toward the ﬂoor even if you are afraid she will fall. If

you have to touch something, grab another pillow for

the landing zone.

When the head slips out, grab the baby under the arms

and bring her up to the mom.

If the baby’s arms are out but the head does not come

with the next contraction, you should have the mother

get out of bed, squat, and push.

KEY POINTS

All parents-to-be should go to

● Childbirth education classes

● Infant/child CPR (cardiopulmonary resuscitation) classes

● Breastfeeding classes

Parents-to-be should keep the family car

● In good repair

● Filled with gas

If you have to labor at home during a terrorist attack or

other emergency

● Call your midwife or physician

● Call for an ambulance

● Call a neighbor to help you

● Unlock the front door

● Keep these instructions and the birth supplies handy!

Women in labor need lots of encouragement and need

helpers who are calm, positive, and caring. No matter what

is happening in the rest of the world, it is important to keep

the room peaceful and to focus on the mother’s needs. She

needs support and reassurance to do the hard work of labor.

Be there for her and her baby.

DISCLAIMER

The information provided in this document is not a do-it-yourself

guide for a planned home birth, nor is it all the information you need

for every emergency. Following these directions will not replace the

knowledge and skills of a doctor or midwife and cannot ensure a

safe outcome. The information is a basic guide for parents-to-be

who want to be ready in case they have to give birth before they can

get to a hospital or birth center. In all cases, it is critical that you

attempt to make contact with a trained health care professional.

Adapted with permission from the American College of Nurse-

Midwives.

52 Volume 49, No. 4, Suppl. 1, July/August 2004