Childbirth and infant survival

Record the date of the last period; birth is due about 40 weeks from it. Check in monthly, then weekly from week 36.

The signs that mean get the trained attendant now, not later: bleeding at any point, severe headache with blurred vision, swelling of face and hands, fits, fever, waters breaking before 37 weeks, the baby's movements stopping, and severe abdominal pain. Feed the mother better than the group's average through pregnancy and while feeding — she needs roughly 300 extra kcal a day in the last two-thirds of pregnancy and 500 while breastfeeding, and iron-rich food daily.

Attendant deaths of mothers were an epidemic of hospitals precisely because attendants did not wash between patients. The whole intervention is six things clean: clean hands, clean surface, clean blade, clean cord tie, clean cord stump, clean perineum.

The attendant washes with soap for 40–60 seconds, nails short and scrubbed, forearms included, and washes again after any contact with anything else — a cloth, a door, another person. Lay the birth on a boiled or sun-dried cloth kept sealed for this. Boil blade and ties for 20 minutes and keep them covered until the moment of use.

Wait 1–3 minutes before cutting — the blood still flowing into the baby is worth a measurable reduction in infant anaemia for months. Tie twice with boiled thread: 2 cm from the baby's belly and again at 5 cm, and cut between the ties with the boiled blade.

Then keep the stump dry and open to the air. Nothing goes on it — no dung, ash, soil, oil, turmeric or bandage. It dries, blackens and drops off in 5–15 days.

Most births need patience, food, water, upright movement and no interference. Every vaginal examination is a chance to introduce infection; do it rarely and with washed hands.

Write down, hourly: contractions in ten minutes, the baby's heartbeat (normal 110–160 a minute, counted for a full minute between contractions), and whether the baby is descending. Labour advancing nowhere for 12 hours, or pushing for more than 2 hours in a first birth or 1 hour in a later one with no descent, is obstructed and will not resolve by waiting — that is the moment to move the mother to whatever better help exists, before she is exhausted.

Heavy bleeding after delivery is the commonest cause of maternal death. Treat anything above about 500 ml, or any bleeding that soaks a cloth in minutes, as the emergency it is. In order, without pausing between:

1. Rub the uterus hard through the belly wall until it clamps down into a firm ball, and keep rubbing.
2. Put the baby to the breast — suckling contracts the uterus.
3. Empty the bladder, which prevents the uterus contracting.
4. Deliver the placenta if it has not come, then check it is complete — a retained fragment keeps the bleeding going.
5. If bleeding continues, compress the uterus between two hands, one fist in the vagina against the front wall, the other pressing the uterus down onto it from above, and hold it. Lie her flat, raise her legs, and get fluids into her by mouth.

Dry the baby immediately, and remove the wet cloth — wet skin loses heat fast, and hypothermia kills small babies. Then skin to skin on the mother's chest, both covered, with a cap on the baby's head. Delay the first bath 24 hours.

Breastfeeding within the first hour and exclusively thereafter: the first milk is thick and yellow and is worth more to the baby than anything else available. Where there is no safe water and no sterilising, any substitute carries a far higher death rate. Watch breathing — 30–60 a minute is normal. A baby not breathing at birth needs drying, rubbing along the back, and the airway cleared; if still not breathing by one minute, give gentle puffs of air, about 40 a minute, watching the chest rise.

Closely spaced pregnancies deplete the mother and raise the death rate for mother and baby both. Wait at least 24 months after a birth before the next pregnancy, and at least 6 months after a miscarriage.

Full breastfeeding suppresses fertility for around six months and then stops being reliable. Say that plainly rather than letting people rely on it. This is a decision with real consequences for the whole group, and it belongs in open discussion — see deciding how you decide — not left to assumption.

This skill must never rest on one person — she will one day be the one giving birth. Two trained attendants minimum, both practising, plus one in training at all times.

Drill the three emergencies until they need no instruction: bleeding after delivery, a baby not breathing, and fits in late pregnancy (lie her on her left side, protect her from injury, put nothing in her mouth, clear the airway once the fit ends, and deliver the baby as soon as possible — magnesium sulphate is the drug that works, when it exists). Write the group's births down — date, length of labour, what happened, what was done. Ten records teach more than any remembered impression. A Book for Midwives is written for exactly this situation; keep a copy.