Labor and Birth

[This information also appears in audio form on episode 2 of the Transition to Parenthood Podcast.]

Overview of the Stages of Labor

Labor has three stages – the first stage is the dilation of the cervix to 10 cm. The second stage is pushing and the delivery of the baby. The third stage is the delivery of the placenta. For an average first time mother, this process takes 14 hours from start to finish. But it’s totally normal for it to take anywhere from 3 hours to 30-something hours.

If someone had a 14 hour labor, we might typically expect that the first stage would take about 12 hours, second stage pushing would be about 90 minutes, and third stage delivery of the placenta would be less than 30 minutes.

That first stage of labor can be further divided into three phases. Early labor is when the cervix is going from 0 to 5 cm. In active labor, the cervix dilates to 8 cm. In transition, the cervix dilates to 10 cm and the baby is engaged on the cervix, ready for birth. If someone’s first stage were to take 12 hours, we might expect that they would be in early labor for 8 hours, active for 3, and transition for 1. So, labor progress speeds up as they move further along in the process. It also gets a lot more intense, with contractions coming closer together, and lasting longer. Because of this increasing intensity, comfort techniques need to change and adapt as labor gets more challenging.

A helpful tool for labor coping is the 3R’s – Relaxation, Rhythm, and Ritual. The concept of the 3R’s was developed by Penny Simkin, a world-renowned doula and childbirth educator. I’ve had the privilege to work with Penny for 20 years now as childbirth educators at the Great Starts program of Parent Trust for Washington Children, and we are co-authors of the book Pregnancy, Childbirth, and the Newborn.

Penny developed the idea of the 3R’s after serving as a doula at hundreds of births – she found that the people who coped best with their labor shared three characteristics – Relaxation – they weren’t holding extra tension and were as relaxed as a person in labor can be, Rhythm – they moved and breathed rhythmically, and Ritual – doing the same thing on every contraction helped them to cope.

Let’s look at how you’ll know that labor has begun and how you can respond to all the stages of labor, using the 3R’s.

Signs that Labor May Begin Soon / Has Begun

There are several possible signs that you may be in labor soon, such as: cramps, restless backache, nausea or vomiting, diarrhea, and nesting urge. There are pre-labor signs, such as vaginal discharge (also known as mucus plug or bloody show) or non-progressing contractions – that means you’re having contractions, but they’re irregular and they aren’t getting any stronger or more frequent. If you’re not sure whether contractions are progressing, try this: drink a glass of water and change your activity (if you were resting, get up and move around. If you were active, rest for a while). An hour later, time the contractions again. Has the pattern changed? If it slowed down or stayed the same, then this is considered pre-labor. (Learn more about the signs of labor.)

If the bag of water breaks, labor may start immediately, or may take several hours to start. But it is considered a positive sign of labor, because if labor doesn’t start on its own within 24 hours, it will likely be induced. (Learn about induction and Lamaze’s Healthy Birth Practice 1: “Let labor begin on its own”.)

The main positive sign that someone is really truly in labor is progressing contractions. That means contractions are getting LONGER, STRONGER, and CLOSER TOGETHER over time. If they started labor with mild 30 second contractions that were 15 minutes apart, then some hours later, they’ll be stronger 45 second contractions that are 8 minutes apart, then in active labor strong 60 second long contractions that are 4 minutes apart, then in transition, intense 90 second long contractions that are just 2 minutes apart.

No matter how a labor starts, those progressing contractions are the key sign of true labor.

Early Labor

Some people start labor with long, intense, frequent contractions. They’ll need to start labor coping techniques soon to manage them.

But, it’s much more common for a first time parent to start early labor with short, mild contractions that are several minutes apart. Don’t over-react to those contractions and start putting energy into working hard on comfort techniques too early in labor. There may be many more hours to go.

If contractions are mild enough that you can ignore them, then ignore them! Rest and relax.

If it’s the end of the day, or the middle of the night, and you’re tired, then sleep if you can (and even if the laboring person can’t sleep, this may be a good time for the support person to catch some zzz’s so they’re rested up later when their support will be more essential). You could try taking a warm bath and drink some warm milk or chamomile tea that might make you sleepy. The bath can sometimes slow down early labor contractions enough to let someone rest till morning. Or you could make love to get the oxytocin going and then cuddle up and hopefully get drowsy enough to sleep.

In the daytime, find pleasant distractions: you can go for walks, or go shopping, or watch a video or work on projects at home – if you need to stop and catch your breath when a contraction happens, then do, but then go back to your distraction.

When labor contractions get strong enough that you can’t possibly ignore them – and this may be 10 minutes after labor started or may be 10 hours after labor started – then start using comfort techniques. With our 3R’s of labor, Relaxation is the biggest focus of early labor. Once you find a Rhythm of responding that is working for you, you stick with it for as long as it works – you make it the Ritual.

In my post on Understanding Labor Pain, I talk about ways to reduce fear, tension, and pain and increase confidence, relaxation and physical comfort. All of those will be helpful. The techniques I have found most helpful in early labor are: slow deep breathing, relaxation techniques, visualization, massage, baths, relaxing walks, and rocking in a rocking chair or porch swing.

The partner’s main role is to help the person in labor feel relaxed, safe, and loved. When we feel loved and loving, safe and nurtured, the hormone oxytocin flows, and this helps the uterus to contract, and the cervix to dilate. It also produces endorphins which reduce pain.

Learn more about early labor.

Moving from Early to Active Labor

At some point, maybe a few hours after labor has begun, or maybe a few days after it has begun, labor will get more intense as active labor begins. There are several clues that someone may be in active labor. First is the contraction pattern – for a first-time parent, we’re looking for the 4 – 1 – 1 pattern. Contractions are less than 4 minutes apart, more than 1 minute long, and you’ve had that pattern for one hour or more. (Note: you can time your contractions with an app – just search your app store and you’ll find plenty of options.)

Beyond the timing of contractions, you’ll also see that contractions are more intense, demanding more from both the person in labor and from the support partners to help her cope with them, and the mood has shifted. We describe this as the can’t walk / can’t talk stage of labor.

It’s not that they can’t talk… some women will chant “I can do it, I can do it… “ or they may say “I can’t… I can’t….” One woman said “epidural… epidural… ” and between contractions said she wasn’t asking for one – she said as long as she could say it she didn’t need it.

What I mean is that they no longer carry on a regular conversation. In early labor, they were chatty between contractions, and narrated their way through contractions. “Wow, these are getting stronger… it starts in my back and wraps around my belly… wow I can even feel it in my thighs now.” That tells me labor is intensifying and she’ll likely soon be in active labor, but she’s not yet.

In active labor, in between contractions she’ll be much more focused – in early labor, we may have chatted about where she grew up or how she met her partner – now if you talk about anything not related to getting this baby out you get a blank stare in response. And during contractions – she either stops talking completely, or starts chanting, or starts vocalizing – maybe moaning or making some other labor noise.

When I say a woman in active labor can’t walk – it’s not that her muscles stop working – she may still stand, sway, rock in a chair, climb stairs. But if she was walking down the hall, there’s usually a point where labor “stops her in her tracks” – where she no longer has the focus to decide where to go, and to figure out how move around things like that chair in the hallway, and she needs to just stop and cope with the contraction.

When someone has reached the 4-1-1 pattern, and can’t walk / can’t talk, that’s typically the active labor phase, and that’s the time when you want to be in the place you plan to give birth. If you’re planning a home birth, you’ll call your midwife to join you. If you’re going to a birth center or hospital, this is the time to go. Make sure you’ve talked to your care provider during prenatal appointments about this decision making and about the process for arriving at the birth place.

Active Labor

Once you’re settled in for active labor, we still want to watch for Relaxation. It will be harder for her to relax during contractions. But we can encourage her to take advantage of the intermittent nature of contractions and relax in between them. During contractions, we help relax her tension as much as possible so she’s not wasting energy on anything other than what labor requires.

But the key of the 3R’s for Active Labor is Rhythm. When we are working well with our bodies, we have rhythm – we jump rope in rhythm, we stir cake batter in rhythm, we hammer in rhythm, we make love in rhythm (unless we’re intentionally varying it just for fun). In active labor, many women develop their own rhythm, and if they do, it’s our job as support people to just follow along and support that. However, if she’s struggling to find and keep a rhythm, then we try to help with that.

One place you’ll notice rhythm is breathing. With the increased in intensity of the contractions, many people speed up their breathing. If her breathing’s still got a nice relaxed feel and a good rhythm to it, we just echo it. We touch in rhythm with her breathing – we talk in rhythm with her. We rock in rhythm with her.

I had one client who would say “hmmm… haw… hmmm…. haw….” If her partner and I said it with her, she relaxed and softened. Remember, any time we do something and her tension decreases, we can keep on doing it. So he and I went hmm-haw… When the nurse came in the room during a contraction to ask a question, we all just looked at her and hmm-hawed till the contraction ended.

As the labor intensified, it became harder for her to hold her rhythm. As the contraction grew, she’d go hmmm – haw – hmm – HA – hmmmmm – HAAAAA…. Her partner and I would hold the rhythm for her hmm-hah, and that would help her re-ground in it. Without us holding the rhythm, she would have  been overwhelmed by the pain.

Now, not everyone can find a new rhythm on their own. Support people, if you notice her struggling to do the slow deep breathing or if she’s lost rhythm then you can help guide her to find a breathing rhythm that works. (This is a nice video on slow breathing, aka diaphragmatic breathing. Here’s another video on breathing and relaxation.)

The “official” breathing technique for active labor is light breathing – let’s practice it now – take in a deep breath to start, and then blow it out in nice light breaths – hee hee hee hee. Or puh puh puh puh. Now, you don’t have to be as loud as I’m being here – I’m being loud so you can hear me. But saying a silent hee or silent puh can remind you to focus on the exhale. If we focus too much on the inhale we can hyperventilate. If we focus on the exhale, the inhale magically takes care of itself, and we don’t hyperventilate. So, if the laboring person has no rhythm, I establish eye contact, and say “OK, breathe with me… breathe in and puh, puh, puh, puh.” Once they have the rhythm, you can help them keep it by touching in rhythm, or nodding in rhythm, or tapping your foot or whatever, you don’t need to keep breathing that fast!

Another breathing technique is slide breathing. I think of this as going up a slide in reverse and then stepping down the ladder. So, take a big deep breath in, then blow it out a little at a time. [In… hee… hee… hee… blow… And in… ]

Try practicing these breathing techniques for a little while each day in pregnancy to help you remember them, and also incorporate slow deep breathing into your day whenever you can. (Read more about breathing techniques for labor.)

During active labor, we can also use touch to reinforce Rhythm. Make sure your massage strokes match the rhythm of her breathing.

Movement is key for rhythm and for helping someone to cope with active labor. Some great options are: walking, standing and leaning on something, while you sway your hips; slow dancing, or sitting on a birth ball and rocking. (See diagrams here. Learn more in Lamaze’s Healthy Birth Practice 2: “Walk, move around and change positions throughout labor.”)

Again, if someone has rhythm on their own, the support people reinforce it, echo it, reassure her that what she’s doing is OK. If she doesn’t have rhythm, we help her to find it, then support it.

I once had a client who told me that privacy was vital to her. She wanted no one at her birth other than her partner, me and the necessary medical personnel. But when we arrived at the hospital, her mother, mother-in-law, and father-in-law were there. I asked if I should ask them to leave, but she said they could stay. At home, she’d had great rhythm and was coping well by moving around a lot. With her family there, she was trying to sit still in a chair and be a good hostess. During a contraction, she’d close her eyes and try to ride it through. I could tell she needed to move, because occasionally she’d squirm and shift around in her seat. I could tell she needed to make noise because every once in a while, a noise would escape. But then at the end of the contraction, she’d open her eyes, put a smile on and say “So… how was your trip?” We went a few hours like that. No labor progress.

Then her family went out to dinner… within moments of them leaving she started to rock. On the next contraction, she started to make some noise. On the next contraction, she got down on her hands and knees and was rocking back and forth and making noise – yes, rhythm!! And where moments ago, she’d been a squirming mass of tension, now she was as relaxed as she could be. So, my job was to sit with her quietly and hold the space to let her do her thing without worrying about being watched or judged. That rhythm and relaxation told me that she was again coping with and working with her labor. Our ritual was supporting that.

Difficult Labor

Some women have especially difficult labors – this often means there’s an issue with baby’s position. The most common sign is back pain: during contractions mom has a lot of pain in her lower back. Another sign is contractions that “couple”: there will be two or three contractions very close together, then a long pause with no contractions, then two or three in a row. Another is that your labor is very painful, but the cervix is slow to dilate.

Why is it a problem: It can mean that baby is posterior or otherwise not lined up well with the cervix and birth canal. With posterior babies, labor is more painful, it takes much longer to dilate to 10 cm, and pushing is slower and more difficult.

What can support people do: Positions: Have mom lean forward as much as possible. Have mom get on her hands and knees and do pelvic tilt exercises. Or mom gets in the “open knee chest” position, and sways her hips back and forth during contractions. Alternate between pelvic tilts and open knee chest for 25-30 minutes. When mom returns to a more upright position, often the baby will move into a better position, and the signs of back labor will fade. Comfort techniques: Hot packs, ice packs, or massage on her lower back (esp. counterpressure or double hip squeeze) will help with discomfort.

Transition

At some point, maybe an hour after active labor began, or maybe many hours later, contractions get even longer, stronger, and closer together as labor moves from active labor into transition. Signs that someone is probably in transition are: long contractions – up to 90 seconds long, frequent contractions – like every 2 minutes…. And yes, that means every 2 minutes you have a 90 second contraction, then a 30 second break, then a 90 second contraction. And they are much stronger than they were earlier in labor – they may even have multiple peaks – during active labor you got used to the pattern of the contraction getting stronger and stronger and then fading away. Now the laboring person will be like “oh, it’s stronger, stronger… oh thank God it’s getting better… no, no, it’s getting worse again!”

In transition, the laboring person has to work a lot harder to cope, and will need a lot more support. They may panic, or despair, or feel completely overwhelmed. It’s the support person’s job to be the calm anchor in the midst of this physical and emotional storm.

The support person helps to find and reinforce any ritual that will help her to cope. Sometimes this is something you’ve planned in advance. Much more often, it’s something we’ve invented in the moment.

I had one client who was having a lot of back pain throughout a prolonged early labor. So, what helped her was to walk between contractions, then when a contraction hit, she would stop, lean against a wall, a chair, a tree… whatever was handy. Her partner or I would come up and press on her lower back during the contraction. When the contraction was ending, we gently stroked her back and went back to walking. We did this for HOURS on end. Then at one point, her partner was sleeping, and I went to the other room to get juice… I thought I had enough time to get there and back between contractions. But when I came back, she was standing and staring at the wall. I said “Did you have a contraction while I was gone?” “Uh-huh.” “How was it?” “I couldn’t get to my wall.” Now, she was 18 inches from the wall… it wasn’t that she couldn’t get there. What she really meant was – I was counting on you to be there to rub my back and you weren’t there. There is so much in labor that is uncertain and overwhelming and the one thing she could count on and predict was that we would be there to rub her back on every contraction. When we weren’t there, the contraction was much harder to manage.

Sometimes I don’t understand why a ritual is helpful but I can see that it is. I can tell it’s working if when I do it, she softens… she Relaxes and has more Rhythm. If I stop doing that thing and she tenses or loses her rhythm – I know it was helpful and return to it.

I worked with one person that held a cotton ball in her hand – as long as she had it, she was calmer – when she dropped it, it distressed her. I didn’t have to understand why – I just had to make sure she had a cotton ball. (When I asked about it a few weeks later, she said she had been holding onto a cotton ball for some reason in early labor when things were manageable, and somehow for the rest of labor if she had the cotton ball, she could get back to that feeling that she was on top of the contractions.)

I worked with someone else who was really struggling to cope, and I just got a sense that she was too much up in her engineering / problem-solving brain and wasn’t working with her body. I got the intuition that if I just talked, it would let her brain shut up. So I talked and talked – about anything that came to mind. And she relaxed and got into a good coping rhythm. At one point, I was feeling self-conscious. So I started to get quieter and quieter – she started losing her rhythm, then she looked up at me, and said “I can’t HEAR YOU.” I resumed talking, she resumed rocking.

When a ritual is working, it’s not my job to understand it, it’s my job to keep it going.

Second Stage: Birth

At some point, whether it’s after a few hours of labor, or a few days of labor, we move from first stage to second stage labor. The contractions may slow down a little, the laboring person may get a burst of fresh energy, she may feel lots of downward pressure, and she may get an irresistible urge to push.

What’s Happening: Cervix has dilated, baby has descended and is ready to be delivered. Contractions continue, 3-5 minutes apart, lasting 45-90 seconds. Contractions may be accompanied by a strong urge to push. Mom’s vocalizations may change to deep grunts or groans. May last anywhere from a few minutes to three hours. Typically 1-2 hours.

When should mom start pushing? Check with nurse or doctor before starting to bear down.

Where you’ll be / Who will be there: At most hospitals, you deliver in the same room you labored in. Some may move you to a delivery room. A doctor (or midwife) and one or more nurses will be there. And, of course, doula and support people.

Breathing and Bearing Down: Caregivers will guide you. Generally: With each contraction, take in a deep breath, then bear down for five to seven seconds, while exhaling or gently holding breath. Then relax briefly, take in a quick breath. Bear down again. Bear down three or four times per contraction. In between contractions, take nice deep breaths and rest.

Comfort: Any of the ideas above. A cold cloth on her forehead or neck is especially popular. A warm washcloth on the perineum may help avoid tears or episiotomy.

What should partners do: Help support mom in chosen position. Help guide pushing efforts and breathing. Lots of encouragement and reassurance. Reinforce caregivers’ suggestions.

[Here is a helpful video about second stage labor. You can also learn more about Lamaze’s Healthy Birth Practice 5: “Avoid giving birth on your back and follow your body’s urges to push”.]

Third Stage / Newborn Procedures

Immediately after birth, they may place the baby up on mom’s belly, or may take it over to a warming table, depending on the condition of the baby and on hospital policy. The doctor will deliver the placenta: you may need to do a few more light pushes. Then the doctor will examine your perineum, and will repair any tears or episiotomy.

Hospital policies vary regarding immediate newborn care, but most hospitals in the Seattle area attempt to leave the baby in its parents’ arms for as much of the first hour as possible, to allow for initial bonding, and first breastfeeding. At the end of one hour, some mandatory procedures are done, including antibiotic eye ointment, and a Vitamin K shot. Typically, the baby is also weighed and measured at this time, and may be given its first bath. (Read Lamaze’s Healthy Birth Practice 6: “Keep mother and baby together – It’s best for mother, baby and breastfeeding”.)

Resources for More Information

• Video: The Essence of Coping with Labor by Penny Simkin
• Lamaze: Stages of Labor and Birth Partner Cheat Sheet