Midwifery and Childbirth

Why This Matters

Childbirth is the single most dangerous routine event in human life. Before modern medicine, maternal death rates ran as high as 1-2% per birth, and infant mortality reached 30% in the first year. Most of these deaths were preventable with basic knowledge: clean hands, recognizing complications early, and knowing when to act versus when to stay out of the way.

Prenatal Care

Good outcomes start months before delivery. A healthy, well-nourished mother with a monitored pregnancy has dramatically better odds.

Nutrition During Pregnancy

Pregnancy increases caloric needs by roughly 300 calories per day — not “eating for two,” but eating somewhat more of the right foods.

Nutrient	Daily Need	Why Critical	Best Sources
Folate (B9)	Double normal	Prevents neural tube defects in first 4 weeks	Liver (weekly), dark leafy greens, beans
Iron	27 mg (nearly double)	Blood volume increases 50%	Red meat, liver, lentils + vitamin C
Calcium	1000 mg	Fetal skeleton development	Dairy, bone broth, ground eggshells
Protein	70-80 grams	Tissue building	Eggs, meat, beans + grains
Iodine	220 mcg	Fetal brain development	Seaweed, ocean fish

Vitamin A Excess Is Dangerous in Pregnancy

While vitamin A is essential, excessive amounts from liver can cause birth defects. Limit liver to once per week during pregnancy. Plant-based vitamin A (beta-carotene from orange vegetables) is safe in any amount.

Regular Checkups — What to Monitor

Even without medical equipment, you can track pregnancy health:

Monthly through week 28, then weekly:

1. Fundal height — Measure from the pubic bone to the top of the uterus with a string or tape. After 20 weeks, centimeters roughly equals weeks of pregnancy. Too small may mean growth restriction. Too large may mean twins or excess fluid.
2. Fetal movement — After 20 weeks, the mother should feel daily movement. After 28 weeks, teach her to count kicks: 10 movements in 2 hours is normal. Decreased movement is a warning sign.
3. Swelling — Mild ankle swelling is normal. Sudden swelling of the face and hands, especially with headache or vision changes, is a danger sign (preeclampsia).
4. Blood pressure — If you have a blood pressure cuff, check regularly. Rising pressure with protein in urine (foamy urine) signals preeclampsia.

Danger Signs During Pregnancy — Act Immediately

Sign	Possible Cause	Action
Heavy vaginal bleeding	Placental problems	Complete bed rest, prepare for emergency
Severe headache + face swelling + vision changes	Preeclampsia/eclampsia	Deliver as soon as possible if near term
Fever with foul-smelling discharge	Infection	Treat infection aggressively
No fetal movement for 12+ hours (after 28 weeks)	Fetal distress	Urgent assessment
Water breaks before 37 weeks	Preterm labor	Bed rest, watch for infection
Seizures	Eclampsia	Protect from injury, deliver immediately

Preparing the Birth Environment

The birth space determines infection risk more than almost any other factor. Historically, puerperal fever (childbed fever) killed more mothers than any complication of delivery itself, and it was caused entirely by dirty hands and unclean environments.

Essential Setup

1. Clean the room thoroughly — Sweep, wash all surfaces with soap and boiled water. Remove animals and unnecessary people.
2. Boil all instruments — Scissors or knife for cord cutting, string or cord clamps, clean cloths. Boil for 20 minutes.
3. Wash hands — The birth attendant must wash hands with soap and water up to the elbows. Wash again before every examination. This single practice cut maternal death from infection by over 90% when first adopted.
4. Prepare clean cloths — At least 6 clean cloths: under the mother, for drying the baby, for wrapping the baby, for cleaning, for managing bleeding, spare.
5. Warm water — Have warm (not hot) water ready for cleaning.
6. Light — Good lighting is essential. Oil lamps, candles, or position near a window.

The Birth Kit

Prepare in advance: 2 pieces of clean string or cord ties (boiled), 1 sharp clean knife or scissors (boiled), 6+ clean cloths, soap, a basin for warm water, a blanket for the baby, and a clean surface for the baby’s first minutes.

Birth Positions

Lying flat on the back is the worst position for childbirth. It compresses major blood vessels and works against gravity.

Better positions:

• Squatting — Opens the pelvis by up to 30%. Uses gravity. Traditional in most cultures.
• Hands and knees — Relieves back pain. Good for large babies.
• Kneeling, leaning forward — Supported by a person or furniture. Comfortable and effective.
• Side-lying — Good when the mother is exhausted. Slows a too-fast delivery.
• Sitting upright or semi-reclined — Supported from behind. Reasonable compromise.

Let the mother choose what feels right. Her body knows.

The Stages of Labor

First Stage — Dilation (Hours to a Full Day)

The cervix (opening of the uterus) must thin and open from closed to 10 centimeters. This is the longest stage.

Early labor (0-6 cm): Contractions are irregular, 15-30 minutes apart, lasting 30-45 seconds. The mother can walk, eat lightly, drink fluids. Encourage rest.

Active labor (6-10 cm): Contractions strengthen to 3-5 minutes apart, lasting 60 seconds. The mother cannot talk through them. She should stay hydrated (sips of water, broth). No heavy meals.

Transition (8-10 cm): The most intense phase. Contractions are 2-3 minutes apart, lasting 60-90 seconds. The mother may feel nauseous, shaky, or say she cannot continue. This is normal and means delivery is close.

What to Say During Transition

“You are almost there. This is the hardest part and it means the baby is coming soon.” These words matter. Transition is when many women panic, and reassurance from a calm attendant makes a measurable difference in outcomes.

When NOT to push: Until the mother feels an overwhelming urge to bear down. Premature pushing before full dilation wastes energy and can cause cervical swelling.

Second Stage — Delivery (Minutes to 2 Hours)

The mother pushes the baby out. For first-time mothers, this can take 1-2 hours. For subsequent births, often 15-30 minutes.

The attendant’s role during pushing:

1. Encourage pushing with contractions, resting between them
2. Watch the perineum as the baby’s head becomes visible (crowning)
3. Support the perineum with a warm, wet cloth — gentle counterpressure reduces tearing
4. As the head delivers, check for the umbilical cord around the neck. If present, gently slip it over the head or loosen it enough for the body to deliver through
5. After the head, the body usually delivers with the next contraction. Support but do not pull
6. The baby may not cry immediately — 30-60 seconds of stimulation (rubbing the back) is normal

Never Pull on the Baby

The baby will rotate naturally after the head delivers. Support it, guide it gently, but pulling risks nerve damage to the baby’s neck and shoulder (brachial plexus injury). Let the mother’s contractions do the work.

Third Stage — Placenta (5-30 Minutes)

After the baby delivers, the placenta must separate from the uterine wall and be expelled.

Signs the placenta is separating:

• A gush of blood
• The cord lengthens (appears to come out further)
• The uterus rises and becomes firm and round

What to do:

1. Wait patiently. Do not pull on the cord.
2. Encourage the mother to push gently when she feels the urge
3. Once delivered, inspect the placenta — it should be complete (one smooth side, one rough side with no missing pieces)
4. If pieces appear missing, the mother is at high risk for hemorrhage and infection. Uterine massage and close monitoring are essential.

Cord Cutting and Clamping

There is no rush to cut the cord. Delayed cord clamping (1-3 minutes after birth) transfers additional blood to the baby, reducing anemia risk.

Procedure:

1. Wait until the cord stops pulsing (turns white and limp) — ideally 1-3 minutes
2. Tie the cord tightly in two places: 2 centimeters from the baby’s belly and 5 centimeters from the baby’s belly
3. Cut between the two ties with a boiled, clean blade
4. Check the cut end — if bleeding, tie again more tightly
5. Keep the stump clean and dry. Do not apply anything to it. It will dry and fall off in 7-10 days.

Unclean Cord Cutting Kills

Tetanus from unclean cord cutting (neonatal tetanus) historically killed millions of newborns. The blade MUST be sterile — boiled for 20 minutes or heated in a flame until glowing. The string or ties must also be boiled. No exceptions.

Managing Hemorrhage

Postpartum hemorrhage (heavy bleeding after delivery) is the leading killer of mothers in childbirth. Blood loss greater than 500 ml is hemorrhage. A soaked cloth holds roughly 100-150 ml.

Immediate Actions for Heavy Bleeding

1. Uterine massage — Place one hand on the mother’s lower abdomen. The uterus should feel like a firm grapefruit. If it is soft and boggy, massage firmly in a circular motion. This stimulates the uterus to contract and close off bleeding blood vessels. Continue until firm.
2. Empty the bladder — A full bladder prevents the uterus from contracting. Have the mother urinate.
3. Breastfeed immediately — Nipple stimulation releases oxytocin, which causes uterine contractions. Put the baby to the breast.
4. Bimanual compression — If massage fails, compress the uterus between two hands: one fist inside the vagina pressing up against the uterus, one hand pressing down on the abdomen. This is painful but life-saving.
5. Fluids — If she can drink, give water, broth, or any available fluid to replace volume.

Prevention Is Better Than Emergency Treatment

Active management of the third stage — uterine massage beginning immediately after placenta delivery — reduces hemorrhage risk by 60%. Do not wait for heavy bleeding to start massaging. Make it routine.

Breech Presentation

About 3-4% of babies present buttocks-first or feet-first instead of head-first.

Detecting breech before labor: Feel the mother’s abdomen. The head is hard, round, and moves independently. It should be felt at the bottom of the uterus. If the hard round shape is at the top, the baby may be breech.

Options:

• External cephalic version (turning the baby before labor) — After 36 weeks, with gentle, sustained pressure, the attendant slowly rotates the baby through the abdomen. Success rate roughly 50%. Stop immediately if the mother has pain or bleeding. This should only be attempted by experienced hands.
• Breech vaginal delivery — Possible but higher risk. The key principle: hands off until the body delivers to the navel, then gentle assistance. The head is delivered last and must not get trapped.

Breech Birth Is High Risk Without Experience

If you have never attended a breech delivery, your primary goal is to prevent one through external version, or to recognize breech early and prepare. A poorly managed breech delivery can trap the baby’s head, which is fatal within minutes. If the baby is coming breech and you cannot turn it, keep the mother upright (gravity helps) and do not pull.

Newborn Assessment and Care

The First Minutes

1. Dry the baby immediately with a clean cloth. Wet babies lose heat rapidly. Discard the wet cloth and wrap in a dry one.
2. Assess breathing — Most babies cry within 30 seconds. If not, rub the back vigorously. Clear the mouth and nose with a clean cloth wrapped around your finger. If still not breathing after 60 seconds, begin gentle mouth-to-mouth-and-nose breaths (tiny puffs — the baby’s lungs are tiny).
3. Skin-to-skin contact — Place the naked baby on the mother’s bare chest, covered with a blanket. This regulates temperature, heart rate, and breathing better than any other intervention.
4. Check for obvious problems — Count fingers and toes, check the palate (cleft), observe movement of all limbs.

Simplified Newborn Assessment

Check	Normal	Concerning
Breathing	Regular, 30-60 breaths/min	Grunting, chest retracting, blue lips
Color	Pink (or normal skin tone), hands/feet may be blue for first hour	Persistently blue or very pale all over
Movement	Active, flexed limbs, strong cry	Floppy, weak or absent cry
Temperature	Warm to touch	Cold hands AND body, or very hot (fever)
Feeding	Rooting, sucking within first hour	No interest in feeding after 2 hours

Breastfeeding

Initiate within the first hour of life. The first milk (colostrum) is thick, yellowish, and contains concentrated antibodies that protect the newborn from infection. Even a few drops are valuable.

Common problems and solutions:

Problem	Cause	Solution
Baby won’t latch	Poor positioning, sleepy baby	Nose to nipple, wait for wide mouth, bring baby to breast (not breast to baby)
Painful latch	Shallow latch — baby on nipple only	Break suction with finger, re-latch with wide mouth taking areola
Not enough milk (first 2-3 days)	Normal — colostrum is small volume	Continue frequent feeding (8-12 times/day). Milk comes in day 2-4
Engorgement (hard, painful breasts)	Milk came in, not draining enough	Warm compress before feeding, cold compress after, frequent feeding

Breastfeeding Is a Learned Skill

Despite being “natural,” breastfeeding often does not come easily. Both mother and baby are learning. Position the baby belly-to-belly with the mother, nose level with the nipple, and wait for a wide open mouth. Most problems resolve with patience and positioning corrections.

Postpartum Care

The First 24 Hours

• Monitor bleeding every 15 minutes for the first hour, then hourly. Normal: gradual decrease, like a heavy menstrual period. Dangerous: soaking more than one cloth per hour, large clots, feeling faint.
• Encourage urination within 6 hours — a full bladder prevents uterine contraction.
• Feed the mother well: broth, eggs, soft foods. She needs calories and fluids for recovery and milk production.
• Help with breastfeeding positioning and latch.

The First Two Weeks

• Lochia (postpartum bleeding) changes from red to pink to yellow-white over 2-4 weeks. A return to bright red bleeding after it had decreased is a warning sign.
• Watch for infection: Fever, foul-smelling discharge, increasing abdominal pain, redness or swelling around any tears or wounds. Treat any infection immediately — postpartum infection can become life-threatening within days.
• Perineal care: If there was tearing, keep the area clean with warm water after urination and bowel movements. Sitz baths (sitting in shallow warm water with a handful of salt) promote healing.
• Rest: The mother should be excused from heavy work for at least 2 weeks. Traditional cultures universally enforced postpartum rest periods — there are good biological reasons for this.

Emotional Health

Mood changes after birth are nearly universal. Mild sadness and weeping in the first two weeks (“baby blues”) affects 50-80% of new mothers and resolves on its own.

Persistent depression, inability to care for the baby, lack of bonding, intrusive thoughts of harm, or psychotic symptoms (hallucinations, paranoia) are medical emergencies requiring community support and close monitoring. Do not leave a mother with severe postpartum symptoms alone with the baby.

When NOT to Intervene

This may be the most important section. Many birth injuries throughout history were caused by attendants doing too much, not too little.

Do NOT:

• Break the water bag (membranes) artificially — let it rupture naturally
• Push on the mother’s abdomen to speed delivery
• Pull the baby during delivery
• Pull the umbilical cord to speed placenta delivery
• Perform vaginal examinations with unwashed hands (or too frequently — each exam increases infection risk)
• Rush any stage of labor that is progressing normally

DO:

• Keep the environment calm, clean, and private
• Encourage the mother, keep her hydrated
• Watch and wait with clean hands ready
• Act decisively ONLY when there is a clear emergency

The Best Midwife Is Often the One Who Does the Least

Throughout most of human history, birth attendants who “did more” had worse outcomes than those who kept their hands clean and watched carefully. Intervention should be reserved for genuine emergencies. A normal birth needs a calm, clean, watchful attendant — not an aggressive one.

What’s Next

Midwifery knowledge connects to broader community health systems:

• Public Health — Maternal and infant mortality reduction is the foundation of population health
• Nutrition Science — Continued nutritional support for nursing mothers and growing infants
• Surgery — Surgical skills for managing severe complications when they cannot be avoided

Midwifery and Childbirth — At a Glance

Prenatal: Monitor fundal height, fetal movement, swelling. Feed mother liver (weekly), eggs, greens, beans, iodine sources.

Birth environment: Clean room, boiled instruments, washed hands (up to elbows), clean cloths, warm water, good light.

Labor stages: Dilation (hours — patience), delivery (minutes to hours — support not force), placenta (5-30 min — do not pull cord).

Cord: Wait for pulsing to stop. Tie in two places. Cut with sterile blade between ties.

Hemorrhage protocol: Uterine massage (firm, circular), empty bladder, breastfeed immediately, bimanual compression if severe, fluids.

Newborn: Dry immediately, skin-to-skin, assess breathing, breastfeed within first hour.

Golden rule: Clean hands save more lives than any technique. Wash before every contact.