How Labor Progresses
Stronger and more regular contractions continue to stretch your cervix until, at around 10 cm, it is fully dilated.
Since every woman’s
experience of labor is different, it’s hard to say exactly what your
experience will be like. However, the stages of labor are common for all
women. The first stage, when labor becomes established, starts when
contractions start to open, or dilate, the cervix (see Dilation).
For some women, especially those who don’t want strong pain relief,
this is the hardest part of labor. Waiting for the cervix to dilate can
be a long process with your first baby, and there isn’t much you can do
to hurry the process. The first stage of labor can be broken down into
different phases, referred to as the early, or latent, phase, and the
active phase. After these phases comes transition, when your cervix becomes fully dilated and before you start to push your baby out (see Support in the first stage).
The early (latent) phase
During the early phase,
which can last for over a day or so in a first labor, your contractions
gradually become more uncomfortable, but still relatively mild, and
occur more frequently, although they may be irregular. During this
phase, your cervix gradually shortens, a process known as effacement
(see Changes to the cervix)
and begins to dilate. When the cervix is approximately 3–4 cm dilated
and you’re having regular, strong contractions, the active phase has
begun (see The active phase). The changes to your cervix during the early phase can be slow or fast and are hard to predict.
The active phase
The active phase of the
first stage is the individual point for each woman where cervical change
happens more quickly and predictably. However, exactly when you enter
active labor can be hard to establish, even for a doctor. For most
women, active labor occurs at around 4 cm dilation. Your contractions
are regular and may be every 5 minutes or so and getting closer together
until they’re 2 to 4 minutes apart and lasting from 45 seconds to one
minute or more. From the start of active labor to the birth can last for
around 10 to 12 hours, although this may be considerably shorter in a
second labor.
In active labor, the
nature of your contractions change, with pain becoming less concentrated
in the lower abdomen, instead starting higher in the abdomen and moving
down toward the pelvis and lower back as your baby is pushed down.
Contractions are caused by a painful tightening of the muscles that may
start off feeling like a severe period pain and increase in intensity as
they reach their peak. Your doctor will assess if you’re in active
labor by observing your pain levels, the frequency and strength of
contractions, and by using a tool called a labor curve, which plots
cervical change and the position of your baby’s head in relation to your
pelvis over time (see partograms).
It’s important for
your doctor to determine when you enter active labor so she can assess
how labor is progressing. For first labors, 90 percent of women have a
cervical dilation of about 1 cm per hour, whereas labor moves faster in
subsequent births. If you’ve had an epidural,
labor may be slower. Once it’s established that you’re in active labor,
the doctor can predict when you may deliver. However, since women vary
widely in how long it takes them to have a baby, bear in mind that this
is only an estimate.
During active labor, you may want to have medical pain relief if you haven’t so far, such as analgesics or an epidural.
Abdominal and vaginal examinations
You will have
several internal vaginal examinations and your abdomen will be palpated
to assess the baby’s position. If your doctor is assessing if amniotic
fluid is leaking, a speculum examination may be done, but in most cases
this isn’t necessary. Usually, the doctor uses her fingers to assess the
baby and the progress of labor. She will try to check you often enough
to make sure that your labor is progressing, but not so often that it
causes you extra discomfort or increases your risk of infection. The
following are assessed during a vaginal examination.
The station
The doctor will check how far the head has descended into the pelvis (see The “station”).
Cervical effacement
The doctor will assess how your cervix is shortening, known as effacement (see Changes to the cervix). Once the cervix is sufficiently shortened, it begins to dilate, or open.
Cervical dilation
The doctor assesses how dilated, or open, your cervix is (see Dilation).
Active labor is established at 3 to 4 cm dilation and full dilation
occurs at around 10 cm. You can’t push your baby out until you’re fully
dilated.
Fetal position
Fetal presentation refers to the part of your baby that is coming out first. Babies can be born head first or bottom first.
Your doctor will also assess which way your baby is facing in the birth
canal. The easiest way for a baby to be born is head down with the back
of the baby’s head (occiput) and spine toward the front (anterior) of
your uterus, known as an occiput anterior position. Your baby can also
be born vaginally from an occiput posterior position (back of baby’s
head and spine toward the back of your uterus), but this can take longer
and be more painful. Vaginal tears are more common when babies are born
in the occiput posterior position. A final position is when your baby
faces your side, known as occiput transverse. Full-term babies can’t be
born in the transverse position since the head is too big to fit this
way. However it’s not uncommon for babies to rotate around during labor,
although this would need to happen before you start to push. If this
doesn’t happen, labor may need to be assisted with forceps or a vacuum
and suction cup .
Descent with contractions
Although most of the
time your doctor will try to examine you inbetween contractions,
sometimes it helps to see how much the baby’s head comes down in the
pelvis during a contraction, referred to as the descent. If there is a
good descent during contractions this means that the baby is fitting
well into your pelvis and that your contractions are efficient.
Transition
Transition is the end of
active labor as your cervix becomes fully dilated and you ready yourself
to begin pushing. This is one of the shortest stages of labor, lasting
from 15 minutes to two hours, although on average it’s about 30 minutes.
This can be one of the most challenging parts of labor because your
contractions intensify and can begin to feel continuous since they now
occur every 30–90 seconds. If you haven’t had an epidural, transition
can be especially difficult since you may feel a lot of pressure on your
lower back and rectum and have an overwhelming desire to push, but will
be unable to push until your cervix is fully dilated. Even if you’ve
had an epidural, you may notice increasing pelvic pressure. If you do
push before your cervix is ready, you may tear your cervix or cause your
cervix to swell and thicken, which will prolong the process of labor.
It’s not uncommon to vomit
now, a side effect of the stretching of your cervix and the pelvic
pressure. You may also tremble or shake and have hot flashes.
How you can cope
You may feel
very uncomfortable during this period as your contractions become
stronger and you try to hold back from pushing. Significant pelvic
pressure during the transition phase can make it difficult to relax
between contractions, and you will therefore need plenty of support from
your birth partner and nurse at this time, since you may be feeling
exhausted, out of control, possibly frightened, and may even think that
you can’t continue.
Work with your nurse
to find the best position for you. This is the one stage of labor where
it can be helpful not to adopt an upright position, since you can take
some of the pressure off the pelvis. Sitting or being on all fours with
your bottom raised may help. Keep breathing during your contractions;
your nurse may show you how to pant and breathe shallowly to help resist
the urge to push. If possible, moving around during contractions can
sometimes help since you will focus on doing something else until you
can actively push. You could try rocking on a birthing ball or in a
rocking chair. If there is time between your contractions, ask your
partner to massage your lower back if this helps relieve pressure.
It can be easy to lose
sight of the purpose of labor at this point, so try to focus on the fact
that your baby will soon be born.
Pain relief
Your doctor may not give
you intravenous pain relief now, since these can cause your baby to be
too sleepy if they are given close to the birth. Depending on hospital
procedure, you may or may not be able to have an epidural now .
Sudden birth
Although uncommon, labor and birth can occur unexpectedly fast,
resulting in an unplanned home birth or a birth on the way to the
hospital. Sudden birth is more likely to happen in second and subsequent
labors or if you’ve had a previous sudden birth.
If you’re alone at home
Try to stay calm and phone
the emergency services for an ambulance. Also ask them to contact your
doctor, whose number should be in your address book. Try to contact a
friend, relative, or a neighbor who can help. If someone is with you,
ask him or her to contact the ambulance and doctor.
Wash your hands and
gather newspapers, clean towels, or clean clothing, or if you have an
assistant ask him or her to prepare in this way. If there is time, the
floor or bed should be covered with a plastic sheet, open trash bags, or
newspapers and have a plastic bowl for the amniotic fluid and blood.
If you have an urge to
push, breathe slowly; panting and blowing can help. Sit or kneel on the
floor or your bed on top of a clean towel so that your baby doesn’t fall
onto a hard surface. Your water may break and an assistant can watch
for a sudden bulging of the perineum and for your baby’s head to appear,
at which point you can push.
Once the head is
delivered, you will feel another contraction and can push the body out.
You may be able do this alone, or an assistant can put his or her hands
either side of the head and apply gentle pressure. If your baby is born
in the amniotic bag, this can be punctured with fingers; the baby’s face
will need wiping so that the airway is clear. Try to record the time of
birth.
Give your baby
immediate skin-to-skin contact to keep him warm; then dry him and wrap
him in a towel or blanket. Putting him to your breast stimulates
contractions to deliver the placenta. An assistant can watch for a gush
of blood or lengthening of the cord, a sign that the placenta has come
away. Put the placenta in a towel in a bowl to be checked. Clamp the
cord with string or a shoe lace; the doctor or paramedic will cut it
when he or she arrives.
If you’re in a car
If you feel an urge
to push, your partner should pull over and put the hazard lights on. If
your baby is born in the car, your partner can put him on your belly for
warmth. If you have towels, dry your baby, wrap him in a clean towel,
and call an ambulance.
If you have an uncontrollable urge to push on your way to the hospital, you may need to pull over and call emergency services.
When it’s time to go to the hospital
Many couples feel unsure about when to go to the hospital.
If your pregnancy is low risk, you will almost certainly be more
comfortable at home at the start of labor and should wait until you’re
in active labor, when your contractions are regular, occurring every
5–10 minutes, and painful, before going to the hospital. At this stage,
the hospital will want to assess how your baby is responding to strong
contractions, and you may want some medication for pain. This needs to
be administered in a setting where you can be monitored and, in the case
of an epidural, can only be given in the hospital.
If your pregnancy is high
risk, you have had a prior cesarean, have a breech baby, or carry the
streptococcus B bacterium, call the maternity ward to discuss when to go
to the hospital.
Once you’re in active
labor, a final reason to go to the hospital is to make sure your baby is
born there. An unplanned home (or car) birth is not best for you or
your baby. This is unusual in a first pregnancy, but with subsequent
births women are more likely to arrive at the hospital quite dilated or
to have an unintended home birth.
Getting to the hospital
Arrange for someone to
drive you to the hospital, either your partner, or a friend or relative;
don’t consider driving yourself. Map the route ahead of time, consider a
dry run before the big day, and have a bag packed with everything you
will need for you and your baby .
Admission procedure
When you get to the
hospital, you’ll be checked in and will be put into a labor room if you
look like you’re in active labor, or into an assessment bed if this
isn’t clear. Usually you will be asked for a urine specimen, and a nurse
will check your temperature, pulse, and blood pressure, check your
cervix, and review your pregnancy history. If you’re in early labor, you
may be sent home. This doesn’t mean you were unwise to come in; it’s
good to ensure all is well.
Once you’ve been
admitted, you and your baby will be assessed by a doctor or nurse.
Sometimes an intravenous (IV) line will be placed and blood tests may be
done. You can make your room comfortable with items from home.
On your arrival at the hospital you will be assessed to see if you are in established labor and should remain at the hospital.
