Stages of Labour

Labour can be mysterious and often feared by many people, but it’s also the way that you get to meet your long-awaited baby. I’ve heard a range of descriptions and ideas about labour and thought that it could be helpful to clear a few things up for those of you expecting, or planning to have children one day, or just speaking with mums about labour and childbirth. Like every week, Mum Will Know is all about educating and providing information which can prepare you and help you to feel confident and understand things in order to make decisions you can be comfortable with.

So in this episode I cover a range of questions including:

What to expect in labour

What are the ‘stages of labour’?

When is it normal to go into labour?

What is a bloody show?

What is the latent phase and how long can early labour be?

What is established labour?

What is transition?

Does position of the baby effect length of labour?

Does mum’s position in labour effect length of labour?

What are good positions for mum to be in in labour?

Firstly labour – what is it? Basically, it is one continuous process which results in the birth of a baby. Labour is often broken down into three or sometimes four stages which assists health care providers in determining if labour is progressing smoothly or whether intervention may be required. There are a number of physical and emotional signs which signify which stage of labour a woman is in.

For most women, labour will commence sometime between their 37th and 42nd week of pregnancy. This is what is known as ‘full term,’ where the baby is fully developed and is just putting on weight as it prepares to be born. In the lead up to labour women often experience stronger and more frequent Braxton Hicks contractions and some describe feeling their baby drop lower in the pelvis as it engages.

What is first stage?

It is where contractions of the muscle layer of the uterus cause thinning out (effacement) and dilation/opening of the cervix. The first stage of labour can be broken into two stages: the latent phase or what’s known as early labour, and the active phase or what is called established labour. Established labour then also has a further stage known as transition.

What is the latent phase of labour?

This is where uterine contractions are present but dilation of the cervix is slow. Early labour can last from just hours to days, even weeks which can be tiring and very confusing! Often due to excitement, as soon as women feel one contraction they are up and packing the car and wanting to head into hospital. However, the best thing to do during early labour is to stay home, get some rest, relax and see what happens.

Women often describe being in labour for 24 or 48 hours, and what they’re really counting is this early stage of labour where contractions are irregular, generally quite short and can easily be talked through. When health care professionals talk about how long labour is this early or latent phase of labour is not counted, and labour is only timed from when it becomes ‘established’. In this early stage of labour some women will notice a ‘bloody show’ come out in the toilet or on their undies. This is basically a bloody or reddish-brown mucous plug that can come out which shows that there are changes to the cervix happening.

What is active labour?

This stage is what’s known as established labour and generally begins when a woman’s cervix is 4cm dilated and she is having regular, strong and long contractions. Labour is now all consuming and usually the woman cannot be distracted or hold up conversation during contractions. As the contractions have become stronger the baby is pushed lower in the pelvis and changes to the cervix happen more quickly. Often care providers will expect to see normal progress of 1cm dilation every 2 hours for first time mums and 1cm every hour for someone who has had a baby before. Active labour is often when a woman emotionally feels she needs more support so this is a great time to call the hospital or have your midwife come to you.

Why is labour painful and what is actually happening?

To get an idea of what is actually going on in labour, in simple terms pain occurs because there is a lack of oxygen reaching the muscle fibres during a contraction. How contractions work is that they cause the upper segment of the uterus to shorten and thicken which slowly means the uterus gets smaller in size and basically forces the baby lower into the pelvis where it hits the cervix and forces it open. In a cyclical fashion, the more pressure that is put on the cervix, the more oxytocin hormone is released which feeds back to the uterus to contract more.

What positions are important in labour?

There’s a lot of research which shows that the positions you are in during labour and for the birth of the baby has been shown to affect not only the comfort of the mother, but also baby’s wellbeing, as well as the how effective the contractions are and how long labour goes for. Upright positions are believed to be optimal as the pelvic diameters (the bony openings that the baby needs to squeeze through) increase when upright, thus making the descent of the baby through the pelvis less obstructed and potentially smoother.

When do your waters break in labour?

The way the movies portray labour as waters bursting in some public place which brings on ridiculously painful contractions straight away where the woman needs to push is not the average woman’s experience. Sometimes waters break (known as rupture of membranes) before contractions start (and sometimes contractions don’t even start on their own and a woman will be recommended an induction), but most often waters break during labour, due to the force of contractions.

What is transition?

So, this phase is still considered part of first stage of labour and is the end phase of active or established labour. Transition is the period generally from about 7 or 8cm dilated to fully dilated and is a time where most women experience very intense contractions and emotions. During transition it is very common to hear women use phrases like “I can’t do this anymore”, “I need an epidural”, “cut this thing out of me”, or “I’m done, I’m going home”. If you and your support person try and remember this phase it may come in handy when you are experiencing it because you can recognise that you’re in transition and it shouldn’t be long before you meet your baby!

What is the second stage of labour?

The second stage of labour is from the point of the cervix being fully dilated (meaning no cervix can be felt around the presenting part of the baby) to the baby being born. Uterine contractions as well as abdominal muscles contract to force the baby through the pelvis and out the vagina (basically this is where whether its uncontrollable or not, you push). In most hospitals the guideline would be that a doctor should intervene and help out if a first-time mum hasn’t pushed the baby out within 2 hours and for someone who’s had a vaginal birth before, one hour.

During the second stage there are a number of factors that work together to impact how smoothly things progress. As mentioned earlier, upright maternal positions can assist in speeding up the pushing stage by increasing the internal diameters of the mother’s pelvis. The baby’s position will also determine whether a vaginal birth is firstly possible and then how easily the baby will navigate through the pelvis to be born. A baby that is lying transverse (sideways) will not be able to be born vaginally as the part of the baby hitting the cervix is likely to be the shoulder or elbow or hip area. The most common position for a baby at term is head down. And the optimal position for the baby to be in is to have its back to the mother’s tummy or front, and to have its head tucked in, chin to chest. Thankfully even if your baby isn’t in this position to start the labour, the way that contractions work by making the uterus smaller and smaller and pushing the baby against the bones of the pelvis and the muscles of the pelvic floor- generally most babies will turn during labour into this optimal position to birth.

Is it normal to poo in labour?

During this pushing stage the bladder is pushed out of the way and the rectum is flattened, meaning that anything that was in the rectum is pushed out – so yes, most women will poo at this stage.

What is the third stage of labour?

The third stage starts once the baby is born and then covers the separation and delivery of the placenta and membranes and any immediate management needed to control maternal bleeding. A lot of people aren’t aware, but once the baby is born the uterus continues to contract and this forces the heavy placenta to shed off the lining of the uterus and as it falls away it pulls with it the membranes on its way into the vagina and out of the body. If you’ve seen a placenta, or can imagine a small dinner plate, this is the size of the open wound left on the inside of your uterus as the placenta is comes away. So, from here it is important that the uterus continues to contract, bringing the opposing sides of the uterus together to put pressure on the open placental site and stop the bleeding.

Blood loss is normal in this process, and a gush of blood is actually a good sign that the placenta has separated from the uterus.

What is considered normal blood loss at birth?

Normal blood loss at birth is considered to be up to 500mls and a haemorrhage is defined as greater than 500mls. However, it is important to note that blood loss of 400mls for a tiny woman who may have had anaemia in pregnancy may have a greater affect and subsequent complications than say a 600mls blood loss from a tall, healthy woman. So, the amount of blood loss doesn’t necessarily correlate to how well a woman will feel postnatally.

What are the management options for the third stage of labour?

In terms of managing this process, there are two ways that should be discussed with you in the lead up to your birth so you can decide what sounds best for you.

- Active third stage management is where a synthetic oxytocin injection is given in the mother’s thigh as the baby is born which causes contraction of the uterus. The umbilical cord is clamped and after a few ‘signs of separation’ are seen by your care provider, controlled cord traction is gently applied to slowly pull/guide the placenta out. Active management is generally recommended in most hospital settings as it is shown to be associated with decreased rates of haemorrhage (bleeding), and it will also decrease the length of third stage. It is also the safest route to take if any other interventions have occurred in your labour eg. use of synthetic oxytocin drip in labour to strengthen or start contractions…

- Physiological third stage is where no intervention is used and things are just left to themselves. Basically, the body continues contracting and delivers the placenta just as it has delivered the baby. Ways to encourage the separation of the placenta physiologically (so without intervening), include breastfeeding – as the baby sucks as the breast, oxytocin is released which stimulates contractions of the uterus. Being in an upright position, like for the birth, can be helpful through the use of gravity. Sometimes maternal effort may be encouraged if time is ticking on, whereby the woman can cough or give a small push which may help the placenta deliver.

It is important to note that if a physiological third stage is what a woman chooses, there is always the option to have the synthetic oxytocin injection and active management if things aren’t looking as if they are properly progressing. For example, in most hospitals, care providers are happy to allow an hour for the placenta and membranes to be birthed if choosing physiological third stage, however if it is getting close to that hour and no signs of the placenta are present, it is likely that the oxytocin injection will be recommended.

It's also important to be aware, is that if a physiological third stage is chosen, then cord clamping should not be necessary and is seen as an intervention which may interrupt the physiological delivery of placenta.

What is delayed cord clamping?

As a little side note, when thinking through the third stage of labour a lot of people ask about delayed cord clamping as there has been some controversy in the past about the benefits to the baby. Delayed cord clamping is where the care provider waits for the baby’s umbilical cord to stop pulsing for more than a minute after the birth of the baby before clamping and cutting it. Research shows positive benefits of delayed cord clamping including higher iron levels due to the fact that the baby is able to get around 80-100mls more blood from the placenta into their bodies. This practice is pretty much commonplace in all hospitals nowadays so shouldn’t even need to be requested – however having that discussion with your care provider beforehand will clear things up.

What is the fourth stage of labour?

This is a less known about, less talked about stage of ‘labour’ which focusses on the first few hours following the birth of the baby. In these hours it is important that a few things happen to aid the new mum’s recovery:

- Contractions continue even once the placenta and membranes are delivered and this is to cause the uterus to get smaller and slow bleeding (women often feel these as afterbirth pains, which are especially strong the more children you have had). The pain is also more noticeable when BF due to the increase in oxytocin as baby suckles at the breast.

- It is also expected that women pass urine in these first few hours following the birth to ensure the bladder doesn’t over fill. Because the bladder is pushed out of the way as baby comes down in second stage it is important to see normal use of bladder again. This is especially important if the woman has had a catheter during labour (like for an epidural) to see that the sensation to void returns and control is maintained as usual.

- Blood pressure drops due to blood loss with the birth.

- Rest, eat and drink. Reenergise!

- Establish breastfeeding (listen to Episode 7 Is Breast Best? Part 2 for more information about this)

And that’s labour… simple…

Listen in to the episode to get more details and if you have any questions contact me through IG or FB @mumwillknow.

Photo by the amazing Jerusha Sutton