Pregnancy – labor

Labor is divided into three stages: the dilation of the cervix, the birth of the baby, and the delivery of the placenta. For first-time mothers, labor takes around 12 to 14 hours. Women who have given birth before can expect about 7 hours of labor.

Recognizing the start of labor#

Braxton-Hicks contractions are sometimes mistaken for labor. These “false” contractions usually start halfway through pregnancy and continue all the way through. You may notice them visibly harden and lift your belly.

It is not known exactly what triggers labor, but it is thought to be influenced by the hormone oxytocin, which causes the uterus to contract. Signs and symptoms of going into labor may include:

• period-like cramps
• backache
• diarrhea
• a small bloodstained discharge as the cervix thins, when the mucus plug drops out (this is called a “show”)
• a gush or trickle of water as the membranes break
• contractions

First stage of labor#

The first stage involves the thinning of the cervix and its dilation to around 10 cm. It is made up of three phases.

• Latent phase: usually the longest and least painful part of labor. The cervix thins out and dilates from zero to three centimetres. This may happen over weeks, days or hours, with mild contractions that may be regular, irregular, or barely noticeable.
• Active phase: marked by strong, painful contractions about three or four minutes apart, lasting 30 to 60 seconds. The cervix dilates from 3 to 7 or 8 centimetres.
• Transition phase: the cervix dilates from 8 to 10 centimetres (fully dilated). Contractions become more intense, painful and frequent, and may feel as though they run into each other. It is not unusual to feel out of control, and to feel a strong urge to go to the toilet as the baby’s head moves down and presses against the rectum.

Throughout the first stage, careful monitoring and recording of your wellbeing, your baby’s wellbeing and the progress of your labor is important. This helps make sure labor is progressing normally and that any problems are recognized early and communicated well.

Second stage of labor#

The second stage runs from when your cervix is fully dilated to the time your baby is born. The contractions during this time are regular and spaced apart. As each one builds to a peak, you may feel the urge to bear down and push.

The sensation of the baby moving through the vagina is often described as stretching or burning, particularly as the head crowns (appears at the vaginal entrance). At the time of birth, a doctor or midwife may guide your pushing to allow a gentle, unhurried birth of the head.

Sometimes the umbilical cord is wound around the baby’s neck. If possible, the doctor or midwife will loosen it, loop it over the head, or clamp and cut it so your baby can be born safely. Once the head has emerged, your midwife or doctor will guide the body so the shoulders come out, and the rest of the baby follows.

If this is your first baby, the second stage can last up to one to two hours, particularly if you have had an epidural. If you have had a baby before, this stage is often much quicker. Monitoring of you and your baby is increased during the second stage, because a long second stage can carry risks for both of you. If labor is not progressing, it is important that the reason is worked out and steps are taken to help you.

Third stage of labor#

After the birth, your uterus gently contracts to loosen and push out the placenta, though you may not feel these contractions. This usually happens 5 to 30 minutes after the birth. The muscles of the uterus keep contracting to stop the bleeding.

This process is always associated with a moderate blood loss, up to 500 ml, which is why the third stage is carefully supervised. One of the potential problems at this stage is excessive bleeding (postpartum hemorrhage), which can lead to anemia and fatigue. There are two approaches to managing the third stage:

• Active management: after the birth, the midwife or doctor gives you (with your consent) an injection of oxytocin, clamps and cuts the umbilical cord, and then gently pulls on the cord to speed up delivery of the placenta. This has been found to reduce excessive blood loss and other serious complications.
• Expectant management: the placenta is allowed to deliver on its own, aided by gravity or nipple stimulation only. The umbilical cord stays connected to the baby until it stops pulsating.

Monitoring your baby during labor#

During labor, your baby’s heart rate is checked regularly. If you have had a low-risk pregnancy and there are no problems at the onset of labor, your baby’s heart will be listened to every 15 to 30 minutes using a small hand-held Doppler ultrasound device or a Pinard (fetal stethoscope). This can be used whatever position you are in.

If you had problems during pregnancy, or if problems arise during labor, your baby’s heart rate may be monitored continuously using a cardiotocograph (CTG). A CTG uses two plastic disks (receivers) strapped to your abdomen and held in place by two belts. The receivers are attached to a machine, which may limit your movement. Some hospitals have machines that let you move around freely while being monitored, which is known as telemetry.

Care of the perineum during birth#

The area between the vagina and anus is called the perineum. Once the baby’s head starts to crown, the perineum will tear if it cannot stretch enough. These naturally occurring tears can be difficult to stitch and may not heal well. In around 3 to 4 per cent of cases, the vagina tears right through to the anus.

An episiotomy is an intentional cut of the perineum, made with scissors. This clean cut is easier to control and repair, tends to heal better than a tear, and is less traumatic to the underlying muscle and tissue. An episiotomy may be needed during the last part of the second stage if:

• you are showing signs that you may tear badly
• the birth needs to be quicker because you or your baby show signs of distress
• you need an assisted vaginal birth

If you are having your first baby, you may help prevent tearing by massaging the perineum in the weeks before the birth. Massaging the perineum during the second stage of labor has not been shown to reduce perineal injury.

Episiotomies should be performed only when needed. They should not be routine, as they do not reduce the risk of severe perineal injury, urinary stress incontinence or trauma to the baby.

Preparing for labor#

Some women find the following helpful in preparing for labor:

• choosing a support person you are comfortable with, who will help rather than distract you
• childbirth education for you and your support person
• yoga and relaxation exercises
• hypnotherapy (a state of relaxation)

Early stages of labor#

Be guided by your doctor or midwife, but general suggestions for a woman approaching labor include:

• once you go into early labor, take the opportunity to rest and relax at home; there is no need to be in hospital until the contractions are regular and painful
• call your support person to let them know your labor is beginning
• once the contractions are around 7 to 10 minutes apart, start timing them by noting how many minutes pass between the start of one contraction and the start of the next
• if you are unsure whether to stay home or go to hospital, ring and speak to one of the midwives, who will ask you some questions and help you decide
• once your contractions are 5 minutes apart, or if you live a long way from your intended place of birth, or if you no longer feel comfortable at home, go to your intended place of birth
• if your waters break or you start bleeding from the vagina, go immediately to hospital

Once you are in your intended place of birth#

Suggestions for labor once you are in your intended place of birth include:

• drink plenty of fluid (such as water, juice or ice blocks) and suck on sweets to keep up your energy
• vary your position to stay as comfortable as possible (standing, kneeling, lying down, straddling a chair, or on all fours)
• have a bath or hot shower
• ask your support person for a back rub or massage
• try to relax between contractions
• if you need or want it, discuss having some pain relief
• resist the urge to push until your cervix is fully dilated (your midwife will let you know when this has happened)
• use gravity to help widen your cervix by walking around, standing or sitting upright
• don’t feel embarrassed by your appearance or behavior; your midwife has seen it all before, so if you want to grunt, yell or swear, go ahead
• remember that passing a bowel motion during labor is normal and nothing to be concerned about

Having a support person#

Having a support person with you can help enormously during labor. Your support person can:

• encourage you and give emotional support
• help make you comfortable
• help with breathing techniques
• provide ice to suck if you are thirsty
• provide a heat pack for your back or a cool face washer for your forehead
• massage your back
• celebrate the arrival of your baby with you

Key points#

• A long second stage of labor can result in risks for you and your baby
• If your labor is not progressing, it is important that the reason is worked out and steps are taken to help you
• There are two approaches to managing the third stage: active management and expectant management

Where to get help#