Childbirth is a natural process which usually takes several hours. This allows time to access the support of a midwife or to transport the woman to a birthing facility. In some cases, an “emergency birth” takes place very quickly and not in the place where it was planned. Childbirth happens naturally without intervention so for an emergency birth, the first aid provider’s role is to support the woman through the process. There are three phases starting with contractions and the woman’s waters breaking, the second phase during which the woman pushes the baby out, and the third stage when the woman pushes the afterbirth out (including the placenta).
Guidelines
- Support the woman to contact her chosen birthing partner, as their continuous support during labour contributes to a positive childbirth experience. **
- During the first stage of labour, being in an upright position (sitting, standing or walking) may help to shorten the duration of labour. *
- During labour, massage of the lower back may reduce pain intensity. *
- During labour, relaxation, yoga, or listening to music may reduce pain intensity and improve the overall birthing experience. *
- Skin-to-skin contact between the mother and the baby may improve breastfeeding, infant and maternal outcomes. *
Good practice points
- The first aid provider should manage the scene to protect the dignity and safety of the woman, as well as taking care to comfort them and give emotional support.
- The woman should be supported to move into the positions she is most comfortable, even if the amniotic sac is broken (waters have broken).
- The woman may drink or eat something during labour if she wants to.
- Hygiene measures should be taken where possible such as wearing gloves and using clean cloths or towels both under the mother and to wrap the new-born in.
- As soon as the baby is delivered, the first aid provider should check both the woman and the baby for their responsiveness, breathing and for any bleeding.
- If the baby is responsive (e.g., crying) and breathing normally, there is no immediate need to cut the umbilical cord and the baby should be dried and kept warm to prevent hypothermia.
- If the baby is unresponsive, the first aid provider should rub the baby dry and tap the soles of its feet. If the baby remains unresponsive and doesn’t start breathing, CPR should be provided as soon as possible. If the presence of the umbilical cord makes this difficult, it should be cut. If possible, the umbilical cord should be tied twice (a hands width apart) with a ribbon and cut in between the ribbons – with the first ribbon about a hand-width from the belly of the baby.
Chain of survival behaviours
Prevent and prepare
- Know how to contact a locally available midwife or other community healthcare provider who can arrive quickly and provide support in an emergency.
- Encourage women expecting a baby to carry contact phone numbers of chosen birthing partners as well as their preferred midwife or birth attendant.
Recognise
Talk to the woman to try to determine whether she is starting labour (which may take several hours) or whether she is having an emergency birth.
The following signs indicate that labour has started, and the baby has entered the birth canal:
- painful contractions occurring at increasingly short intervals
- abdominal discomfort
- localised back pains
- the woman’s waters break
- sticky discharge.
In this instance, support the woman to notify her chosen birthing partner and preferred birth attendants, or to support her transportation to her chosen birth facility.
Childbirth might be imminent, when:
- the contractions quickly become more intense and painful
- the contractions come in short intervals (one contraction every five minutes)
- the woman’s waters break.
If it becomes clear that the baby will arrive very soon or the woman is in too much pain to travel, prepare to support the woman through the emergency birth.
First aid steps
Initially, the first aid provider’s key priority is the woman in labour. Once the baby is being born, the first aid provider has two people to care for: the woman and the baby.
- Access help (such as medical facilities, EMS or a midwife) in line with the woman’s wishes and listen to their instructions. Support the woman to contact her chosen birthing partner.
- In the first phase of childbirth, create a comfortable, private and protected space for the woman. Help her move into a position of comfort. This may be sitting, standing or moving around.
- Massage her lower back or offer relaxation methods such as yoga or listening to music as this may reduce her pain and anxiety and improve the overall birthing experience.
- In the second phase of childbirth, help the woman to find a comfortable position, preferably upright. If she prefers to lie on her back, put a small pillow under the right hip. In this way, you prevent the baby from pressing on important blood vessels.
- If possible, wash your hands well with soap and water and place a clean cloth under the woman where the baby will be born. When the woman is ready to push, ensure she is in a supported position.
- Watch the baby’s head as it comes out and ensure it is supported. Newly born babies are slippery, so be very careful.
- Use a clean cloth to dry off the baby. Wrap the baby in a clean cloth and cover the baby’s head to keep it warm. Keep the mother warm as well and place the baby on the mother’s chest or abdomen as soon as possible.
- In the third phase of childbirth, support the woman as she delivers the afterbirth. Keep the afterbirth as a healthcare professional will need to check it is complete. Check to see if the mother is bleeding. Mild bleeding from the birth canal is normal. If bleeding is severe, help the woman to lie down and keep her warm (see Shock) until medical help arrives.
_____________________________
CAUTION
- Hygiene measures should be taken where possible such as hand washing and wearing gloves and using clean cloths or towels both under the woman and to wrap the new-born baby in.
- Do not pull the baby’s head and shoulders during delivery.
- Do not push on the woman’s stomach during labour or after delivery.
- If the umbilical cord is wrapped around the baby’s neck during delivery, check that it is loose and carefully ease it over the baby’s head to prevent the baby from strangulation.
- Do not pull on the umbilical cord. The afterbirth usually comes out by itself within about 30 minutes of the delivery.
- If the baby is responsive and breathing normally, there is no immediate need to cut the umbilical cord, which should be performed by a medical professional, if possible.
______________________________
______________________________
NOTE
- The woman may drink or eat something during labour if she wants to. This will help her keep up her strength.
______________________________
______________________________
SPECIAL CASE
Unresponsive and abnormal breathing baby
- If the baby is quiet, open their airway and check for breathing. If the baby is breathing abnormally (gasping, taking irregular breaths or not breathing), place the baby on a firm surface and begin CPR as described in Unresponsive and abnormal breathing (baby and child).
If CPR is difficult because of the umbilical cord, cut the cord. To do this, if possible, tie a ribbon or string around the cord in two places a hand width apart so blood can no longer flow through the cord. Then cut the cord in between the two ribbons.
______________________________
Access help
- EMS may be appropriate in many cases of childbirth, or the woman may have a preferred midwife or birth attendant. Consider contacting another local midwife or other community health worker if these are not available.
- Phone EMS, medical facilities (or another healthcare provider) as they will be able to tell you what to do and support you.
- Tell EMS (or chosen healthcare provider) about any changes in the woman or baby’s condition.
Education considerations
Context considerations
- Childbirth has very strong social and cultural references and expectations. Programme designers should adapt the learning to address local cultures and contexts.
Learner considerations
- Childbirth can be unpredictable, so parents-to-be in any context should consider learning this topic. Emphasis on the natural process of birth is important to reduce their anxiety.
- In remote areas where it is difficult to travel or there is no accessible maternity service nearby, the partner and family members of a pregnant woman might also consider learning about this topic.
- In many countries, taxi drivers are a key learner audience for this topic.
- Learners more likely to do emergency childbirth in a car could learn and practise childbirth in the car. The mother could lie on the seat, with one foot on the floor and the other on the seat, with the knee and hip bent.
- Encourage community health workers and volunteers to understand this topic in the context of first aid, and to develop links with their local clinical team.
- People with varying gender identities can give birth (e.g., a man with a uterus). Be sensitive to gender identities in discussing this topic according to the needs of the audience and respecting all opinions without making value judgements.
Facilitation tips and tools
- Emphasise accessing medical help as soon as possible and supporting the woman through the childbirth process.
- Help learners understand the three phases of childbirth. Using pictures or diagrams can be helpful.
- Contractions and waters breaking.
- The birth itself.
- The expulsion of the afterbirth (placenta and umbilical cord).
- A woman who goes into childbirth unexpectedly might be very anxious. Allow learners to practise reassuring her, making her comfortable and helping her to breathe. Reassure learners by emphasising that during this time, if it is possible, they should be following the instructions of EMS (or another healthcare provider).
- A unique aspect of this first aid topic is the changing focus for the first aid provider, who initially needs to focus on the woman and her wellbeing, but then needs to care for two people once the baby is born. Primacy must be given to the woman until the baby is born.
- Use different learning materials and styles including discussion and storytelling to develop confidence in learners. Encourage those who have experienced childbirth (even if not as an emergency) to share their experiences with those who have not experienced it.
- If possible and appropriate, invite a midwife to the education session to talk to learners and answer their questions.
Learning connections
- A new-born baby may be or become Unresponsive with abnormal breathing.
- A woman may experience Severe bleeding during childbirth, and this may develop into Shock.
- Emphasise Hand hygiene.
Scientific foundation
Systematic reviews
No scientific evidence is available, which address specific issues of emergency birth, so the Centre for Evidence-Based Practice (CEBaP) extrapolated from “normal” deliveries.
Birth companion
There is evidence from one Cochrane systematic review including 26 clinical trials in favour of continuous support by a chosen birth companion. In making this evidence conclusion, a higher value was placed on subjective rating or feelings about the birth experience over the other outcomes. It was shown that continuous support by a chosen birth companion resulted in a statistically significant decrease of the occurrence of negative ratings or feelings about the birth experience, compared to standard care. In contrast, it was shown that continuous support by a chosen birth companion did not result in a statistically significant difference in the use of any analgesia or anaesthesia, synthetic oxytocin and the occurrence of spontaneous vaginal birth, compared to standard care.
Furthermore, a statistically significant decrease of caesarean birth or admission to special care nursery, using continuous support by a chosen birth companion compared to standard care, could not be demonstrated. Evidence is of moderate certainty and results cannot be considered precise due to the large variability of results and the low number of events.
Massage during delivery
There is low-certainty evidence from one systematic review in favour of massage (of the lower back).
- It was shown that massage resulted in a statistically significant reduced pain intensity in the first stage of labour, compared to usual care. However, a statistically significant difference could not be demonstrated for pain intensity in the second and third stage of labour, or the use of pain relief.
- It was shown that massage resulted in a statistically significant reduced anxiety in the first phase of the labour, compared to usual care. However, a statistically significant difference could not be demonstrated for anxiety in the second and third stage of labour.
- It was shown that massage resulted in a statistically significant reduced risk of resuscitation of the new-born, compared to usual care. However, a statistically significant difference could not be demonstrated for admission to a neonatal intensive care unit.
- It was shown that massage resulted in a statistically significant reduced risk of perineal trauma, compared to usual care. However, a statistically significant difference could not be demonstrated for postpartum haemorrhage.
Relaxation
There is limited evidence from ten randomised controlled trials included in one Cochrane review in favour of relaxation, yoga or music.
Low-certainty evidence from two randomised controlled trials showed that relaxation resulted in a statistically significant reduced pain intensity (latent phase) and increased satisfaction with pain relief, compared to usual care. However, a statistically significant difference in pain intensity (active phase), pain intensity (total score), satisfaction with childbirth experience, length of labour, assisted vaginal birth, Caesarean section, use of pharmacological pain relief, anxiety, or fatigue in labour, compared to usual care, could not be demonstrated in four studies.
Low-certainty evidence from two randomised controlled trials showed that yoga resulted in a statistically significant reduced pain intensity (latent phase), increased satisfaction with pain relief in labour (latent phase), increased satisfaction with childbirth experience, reduced length of labour, decreased use of pharmacological pain relief, compared to usual care or supine position. However, a statistically significant difference in the use of pharmacological pain relief or need for augmentation with oxytocin compared to usual care, could not be demonstrated in one study.
Low-certainty evidence from two randomised controlled trials showed that music resulted in a statistically significant reduced pain intensity (latent or active phase or transition) and reduced anxiety (transition) compared to usual care or blank CD.
However, a statistically significant difference in Caesarean section, anxiety (latent or active phase), assisted vaginal birth, admission to special care nursery, use of pharmacological pain relief or length of labour, compared to usual care or blank CD could not be demonstrated in one study.
Restriction of oral fluid and food intake
Moderate-certainty evidence from one Cochrane systematic review could not demonstrate a statistically significant improvement in health-related maternal or foetal outcomes, using any or complete restriction of oral fluid and food compared to some fluid and food or freedom to eat and drink.
Heat or cold application
CEBaP identified low-certainty evidence (downgraded for risk of bias and imprecision due to the low number of events and wide confidence intervals) from one Cochrane systematic review neither in favour of heat nor cold application. It was shown that warm compresses resulted in a statistically significant decreased risk of 3rd or 4th-degree tears, compared to hands-off or no warm compresses. However, a statistically significant difference in intact perineum, perineal trauma not requiring suturing, perineal trauma requiring suturing, 1st, 2nd, 3rd or 4th-degree tear or episiotomy, using warm compresses compared to hands-off or warm compresses could not be demonstrated. In addition, a statistically significant difference could not be demonstrated for 1st-degree tear or episiotomy using cold compresses compared to no compresses.
Body position
First phase of labour
CEBaP identified moderate-certainty evidence (downgraded for risk of bias) from one Cochrane systematic review, showing that an upright position (sitting, standing or walking) seems to have better maternal outcomes than a lying position during the first phase of labour.
It was shown that upright and ambulant positions resulted in a statistically significant decreased duration of first stage labour, a decreased risk of caesarean birth and a decreased risk of maternal pain, compared to recumbent positions and bed care (Lawrence 2013). However, a statistically significant difference in spontaneous vaginal birth, operative vaginal birth, maternal satisfaction, maternal comfort, maternal anxiety, duration of second stage of labour, augmentation of labour using oxytocin, artificial rupture of membranes, estimated blood loss greater than 500 mL, perineal trauma, using upright and ambulant positions compared to recumbent positions and bed care, could not be demonstrated.
It was shown that sitting resulted in a statistically significant decreased duration of first stage labour and a decreased risk of operative vaginal birth, compared to lying down, lying on the back or laying on the side. However, a statistically significant difference in spontaneous vaginal birth and caesarean birth, using sitting position compared to the lying down positions, could not be demonstrated. Furthermore, a statistically significant difference in duration of first labour, and caesarean birth when sitting compared to bed care, could not be demonstrated.
It was shown that walking resulted in a statistically significant increase in spontaneous vaginal birth, a decreased duration of first stage labour and a decreased risk of operative vaginal and caesarean birth, compared to recumbent/supine/lateral positions. Furthermore, a statistically significant difference in duration of first labour, spontaneous vaginal birth, operative birth and caesarean birth, using walking compared to bed care, could not be demonstrated.
A statistically significant difference in the duration of first labour, spontaneous vaginal birth, operative birth and caesarean birth, when sitting, standing, squatting, kneeling or walking compared to lying down on the back or side, could not be demonstrated.
There is low-certainty evidence from one Cochrane systematic review showing that a statistically significant difference in foetal distress, use of neonatal mechanical ventilation, Apgar scores and perinatal mortality, using upright and ambulant positions compared to recumbent positions and bed care, could not be demonstrated.
Second phase of labour
During the second stage of labour, the effects are less straightforward. Delivery appears to proceed faster in an upright position, with less assisted births and a lower risk of abnormal heart rhythms in the foetus. But this is at the expense of perineal tearing and a higher risk of a lot of blood loss than with a lying position.
CEBaP identified moderate-certainty evidence (downgraded for risk of bias) from one Cochrane systematic review showing that any upright position resulted in a statistically significantly decreased risk of assisted delivery and duration of the second stage of labour, compared to the supine position. In contrast, it was shown that any upright position resulted in a statistically significantly increased risk of second-degree perineal tears and episiotomy and an increased risk of blood loss greater than 500mL, compared to the lying on the back. Furthermore, a statistically significant difference in any analgesia or anaesthesia during the second stage of labour, caesarean section, 3rd or 4th-degree tears and the need for blood transfusion, using any upright position compared to lying on the back, could not be demonstrated.
In addition, CEBaP identified low-certainty evidence (downgraded for risk of bias and imprecision due to the low number of events) from one Cochrane systematic review showing that any upright position resulted in a statistically significant decreased risk of abnormal foetal heart rate, compared to the supine position. However, a statistically significant difference in perinatal mortality, using any upright position compared to the supine position, could not be demonstrated.
Early skin-to-skin contact
There is low-certainty evidence from one Cochrane systematic review in favour of skin-to-skin contact between the mother and the baby, immediately after the baby is born, which would improve breastfeeding, infant and maternal outcomes. It was shown that skin-to-skin contact resulted in a statistically significant increased number of mothers breastfeeding 1-4 months post-birth, increased duration of breastfeeding, increased number of mothers exclusively breastfeeding at hospital discharge to one-month post-birth, increased number of mothers exclusively breastfeeding 6 weeks to 6 months post-birth, increased success of first breastfeeding, increased successful first breastfeeding (IBFAT 10-12 or BAT 8-12), increased mean variation in maternal breast temperature 30-120 min post-birth, and reduced breast engorgement (pain, tension, hardness) three days post-birth, compared to standard care. However, a statistically significant difference in the number of mothers with a breastfeeding status day 28 to 1-month post-birth, number of mothers breastfeeding 1-year post-birth, number of babies suckled during the first 2 hours post-birth, using skin-to-skin contact compared to standard care could not be demonstrated.
It was shown that skin-to-skin contact resulted in a statistically significant increased SCRIP score first six hours post-birth, increased blood glucose (mg/dL) at 75-180min post-birth, increased infant axillary temperature 90-150min post-birth, increased number of infants who did not exceed parameters for stability, increased number of infants who did not cry more than 1 min during 90 min, decreased amount of crying in minutes during a 75-minute observation period, compared to standard care. However, a statistically significant difference in respiratory rate 75-120min post-birth, heart rate 75-120min post-birth, number of infants transferred to the neonatal intensive care unit, infant body weight change (grams) day 14 post-birth, infant hospital length of stay in hours, using skin-to-skin contact compared to standard care could not be demonstrated.
It was shown that skin-to-skin contact resulted in a statistically significant reduced maternal state anxiety 8 hours to 3 days post-birth, increased PCERA dyadic mutuality and reciprocity 12m post-birth, increased mother’s most certain preference for same post-delivery care in the future, compared to standard care. However, a statistically significant difference for PCERA maternal positive affective involvement and responsiveness 12m post-birth, maternal parenting confidence at 1-month post-birth, maternal pain 4 hours post-caesarean birth, using skin-to-skin contact compared to standard care could not be demonstrated.
Cutting or clamping the umbilical cord (technique)
CEBaP could not identify any scientific studies on the umbilical cord cutting technique.
There is moderate-certainty evidence (downgraded for imprecision due to limited sample sizes and wide confidence intervals) from one Cochrane systematic review, neither in favour of early cord clamping (i.e. within 60 seconds of the birth of the infant) nor late cord clamping (after 60 seconds of the birth of the infant). There is insufficient evidence available to cord clamping for preterm babies who need resuscitation immediately after birth because these cases were mainly excluded or withdrawn from the Cochrane review.
Non-systematic reviews
A few scientific studies are available which focus on the risk of umbilical cord prolapse after the waters have broken (occurring approximately 0.4% of births) (Dekker, 2018). The outcomes of umbilical cord prolapse have improved within the past 10-20 years and more recent studies (from 2002-2012) show that deaths of babies related to umbilical cord prolapse have become extremely rare, mainly associated with prematurity.
Furthermore, there are no studies that test whether bed rest reduces the risk of cord prolapse in women with term PROM (“premature” rupture of membranes before the start of labour past 37 weeks of gestation) (Evidence-Based Birth).
References
Systematic reviews
Centre for Evidence-Based Practice, Belgian Red Cross-Flanders. (2020). Evidence summary Emergency childbirth – Birth companion. Available from: https://www.cebap.org/knowledge-dissemination/first-aid-evidence-summaries/
Centre for Evidence-Based Practice, Belgian Red Cross-Flanders. (2019). Evidence summary Emergency childbirth – Cutting/clamping the umbilical cord (technique). Available from: https://www.cebap.org/knowledge-dissemination/first-aid-evidence-summaries/
Centre for Evidence-Based Practice, Belgian Red Cross-Flanders. (2016). Evidence summary Emergency childbirth – Cutting/clamping the umbilical cord (timing). Available from: https://www.cebap.org/knowledge-dissemination/first-aid-evidence-summaries/
Centre for Evidence-Based Practice, Belgian Red Cross-Flanders. (2019). Evidence summary Emergency childbirth – Massage during delivery. Available from: https://www.cebap.org/knowledge-dissemination/first-aid-evidence-summaries/
Centre for Evidence-Based Practice, Belgian Red Cross-Flanders. (2019). Evidence summary Emergency childbirth – Heat/cold application. Available from: https://www.cebap.org/knowledge-dissemination/first-aid-evidence-summaries/
Centre for Evidence-Based Practice, Belgian Red Cross-Flanders. (2019). Evidence summary Emergency childbirth – Relaxation. Available from: https://www.cebap.org/knowledge-dissemination/first-aid-evidence-summaries/
Centre for Evidence-Based Practice, Belgian Red Cross-Flanders. (2019). Evidence summary Emergency childbirth – Restriction of oral fluid and food intake. Available from: https://www.cebap.org/knowledge-dissemination/first-aid-evidence-summaries/
Centre for Evidence-Based Practice, Belgian Red Cross-Flanders. (2019). Evidence summary Emergency childbirth – Position during labour. Available from: https://www.cebap.org/knowledge-dissemination/first-aid-evidence-summaries/
Centre for Evidence-Based Practice, Belgian Red Cross-Flanders. (2019). Evidence summary Emergency childbirth – Early skin-to-skin contact. Available from: https://www.cebap.org/knowledge-dissemination/first-aid-evidence-summaries/
Non-systematic reviews
Dekker, R, (2018). Evidence for going on bed rest during labor if your water breaks. Evidence-Based Birth. Retrieved from https://evidencebasedbirth.com/if-my-water-breaks-do-i-have-to-go-on-bed-rest/ (access 28.8.2020)
Related topics
Explore the guidelines
Published: 15 February 2021
First aid
Explore the first aid recommendations for more than 50 common illnesses and injuries. You’ll also find techniques for first aid providers and educators on topics such as assessing the scene and good hand hygiene.
First aid education
Choose from a selection of some common first aid education contexts and modalities. There are also some education strategy essentials to provide the theory behind our education approach.
About the guidelines
Here you can find out about the process for developing these Guidelines, and access some tools to help you implement them locally.