Stages of Labor Overview
First stage labor is when the cervix dilates to 10 cm. First stage has three phases: early labor, active labor, and transition. That process may take anywhere from a few hours to a few days. Second stage is from when the cervix reaches full dilation to when the baby is born. Second stage can take minutes to hours. For the majority of first-time parents without an epidural, pushing takes 3 hours or less. Third stage labor is the delivery of the placenta, which takes 10 to 30 minutes for most people.
How will you know second stage has begun?
After the intensity of transition, contractions may slow down a little and may become a little less intense. The laboring person may have a burst of energy or may sort of perk up and re-connect with those around her.
During contractions, the laboring person may feel a lot of downward pressure. The key sign of second stage is the Urge to Push. Many will say “I feel like I need to poop” because that’s the closest sensation they’ve had to this experience before now. Soon, an irresistible urge to bear down may develop. This urge is sort of like when you have an urge to sneeze. At first, you have the hints a sneeze is coming, but you can hold it back. Soon, you just can’t control it, and you find yourself sneezing uncontrollably in the midst of merging onto the highway or right in the middle of a performance. The urge to push can be like that.
Occasionally the urge to push comes before someone has reached full dilation and they may be asked not to push yet. But it’s hard to resist completely. One of my clients once declared “I’m not pushing – the baby’s pushing!”
People with epidurals may not feel the full urge to push, but with modern epidurals, most will at least have a sense of strong downward pressure.
Even without an epidural, some people do not have the urge right away. Sometimes the nurses notice a change in the labor pattern and do a cervical check and find that the cervix is 10 cm, but there’s no urge to push. This is called the “rest and be thankful” phase. Not everyone has one, but if you do, take the opportunity to relax for a few minutes and gather the energy for what’s to come. Especially with an epidural, a care provider may suggest that someone “labor down” – just resting until the uterine muscles have pushed the baby down low enough that the urge to push arrives or until the baby is crowning.
When you’re ready to move labor along, try changing positions – get more upright, sit on a toilet or a birth ball, or with an epidural, try putting a peanut ball or pillow under one knee. Changing the shape of the pelvis allows the baby to descend and may trigger the urge to push.
When the urge arrives, notify a nurse or caregiver. They may do a cervical check before having someone start pushing to be sure the cervix is fully dilated. They may ask the laboring person to do a couple of “test pushes” to see how that goes.
Positions for Pushing
If second stage goes quickly, the laboring person may just push in whatever position they happen to be in. If it’s a long pushing stage, it can be helpful to try several different positions to help the baby move down. (see illustrations of positions for birth)
Upright positions help second stage go faster, as gravity helps baby to descend. And positions which open up the pelvis create more space for the baby to move through. Upright positions mean that a vacuum or forceps delivery or episiotomy is less likely. People who were able to choose upright positions tend to have less pain and be more satisfied with their experience.
Which positions are options for you depend on whether or not an epidural is being used, and on what positions the care provider recommends.
Without an epidural, standing and then squatting during contractions might be an option. Sitting on a birthing stool is a similar position, but less tiring to maintain. Someone with an epidural can squat on the bed with the support of a squat bar. Squatting is an upright and open position and leads to a faster delivery but that also means there’s a higher chance of tearing.
Being on hands and knees or kneeling with one leg up means the pelvis can open all the way and the birthing person can shift position to accommodate the baby. However, not all caregivers deliver babies in this position, and with an epidural, the laboring person needs extra support getting into this position and staying there.
Side-lying is a restful position and works whether or not pain medications are being used. Side-lying slows down a fast pushing stage and puts the least pressure on the perineum so it reduces the chance of a tear.
Semi-sitting, where the birthing parent is on the bed, leaning against the raised head of the bed, is a common birthing position. It’s upright, but the pelvis is somewhat compressed as her weight is resting on the sacrum. Semi-sitting is the easiest position to maintain for someone with an epidural.
Many women are asked to give birth while lying on their backs, but this is not the most efficient position for the birthing parent. Semi-sitting or supine may be the easiest position for the caregiver for monitoring and for delivery of the baby.
With side-lying, semi-sitting, and supine positions, the partner may be asked to help hold up her leg while she pushes.
Ask your caregiver at a prenatal appointment which positions they recommend. Some may be open to a wide variety of positions during the descent portion of second stage, but ask that you be in a prescribed position for the actual delivery of the baby.
If you want squatting to be an option for you at birth, it can help to do squatting exercises during pregnancy to increase the flexibility of your joints and strengthen your muscles.
How long and how hard should someone push?
If someone has an urge to push, they may be able to just follow that, pushing when they feel the urge, for just as hard as they need to and just as long as they feel the urge. Consider this metaphor: “how do you know when to sneeze? And how many sneezes to do, and how strong those sneezes need to be? It’s something your bodily instincts just take care of.”
This is called spontaneous pushing, and research shows that for a birthing person who is able to follow her urge to push, it is very effective and safe.
If someone can’t feel the urge to push, or is not able to work effectively with it, the caregiver may use directed pushing and coach through the contraction. Something like “OK, take a deep breath, and push 2 – 3 – 4 – 5 – 6. Good, take a few breaths and now push 2 – 3 – 4 – 5 – 6, take a few breaths and push 2 – 3 – 4 – 5 –6, OK, relax, this contraction is almost over, just breathe and relax.” In between contractions, everyone rests and re-gathers their energy.
Occasionally, if there’s any concern about the baby the caregiver might use prolonged pushing, where the birthing parent is encouraged to push as hard as they can for up to 10 seconds at a time, but this is typically not done.
How does pushing work?
The involuntary muscle contractions of the uterus do most of the work. Your active pushing efforts help support that. Often, you’ll be directed to tuck your chin, lift your legs open and bear down. Obstetricians used to recommend holding your breath while pushing. We now know that most women push more effectively when they relax their mouth and throat. They often grunt or groan while pushing. (If someone is screaming during pushing, that’s less likely to be effective, as they may be putting all their energy into the yelling.)
While pushing, you need to simultaneously tighten your abdominal muscles and relax your pelvic floor muscles. That sounds tricky, and it can be. Most people figure it out quickly enough in labor.
But, if you would like to practice it in pregnancy, there’s an app for that. Actually, really there is… on iTunes you can download the How to Push Out Your Baby app to learn this method. I will briefly walk you through the three steps here. You can learn about the separate exercises in our book Pregnancy, Childbirth and the Newborn – this just puts them all together into one.
First, do Slow Deep Breathing. Take a deep breath in though your nose, letting your belly expand, then your chest. Now breathe out through your mouth. Rest your hands on your belly. Take a deep breath in – as your belly expands, your hands separate a bit. As you breathe out, your hands come back together.
Now, do a Transverse Abdominal Contraction. This is like when you’re trying to button a tight pair of jeans, and you “suck in your gut.” You pull all your abdominal muscles toward your belly button as you pull your belly button toward your spine. A pregnant person can imagine using all those muscles to give the baby a hug. Hug the baby high and tight, and you’ll notice the baby moves up and in just a bit.
This is a great exercise for strengthening belly muscles, and the stronger your abdominal muscles, the less back pain you’ll have.
Now, let’s combine slow breathing and abdominal contraction. As you breathe in, let your belly expand. As you breathe out, then tighten all those muscles, pulling your belly button toward your spine. Relax, and breathe in, letting the belly expand. Breathe out, contracting those muscles.
The third exercise is pelvic floor relaxation. (Don’t try this if you need to pee right now!)
You may already know about Kegels – this is an exercise for the pelvic floor muscles where you tighten all those muscles – imagine you were sitting on the toilet and wanted to stop the flow of urine, or if you were trying to hold in a fart – you’d tighten the muscles of your pelvic floor. So, let’s practice that and add relaxation at the end. So tighten your muscles, and imagine that as you tighten more and more, you’re lifting up your pelvic floor like an elevator to the first floor, second floor, third floor. Now as you relax, the elevator slowly drops to the second floor, first floor, now give just a little push to bulge the pelvic floor down to the “basement.” Got that? Try it again, tighten up 1 – 2 – 3, then relax 3 – 2 – 1 and a little bulge down. Then relax.
Here’s a couple other ways to think of relaxing your pelvic floor – imagine that there’s a heavy weight in your vagina pulling downward. Or, imagine you’re in a big hurry to go to the bathroom so you can get back to a movie, and you’re trying to pee really fast so you push down just a little bit as you pee.
Now, to practice for coordinated pushing, we’re going to put all those pieces together – the slow breathing, the transverse ab contraction and the pelvic floor relaxation.
So, take a deep breath in, letting your belly expand. As you exhale, tighten those belly muscles to give baby a hug AND bulge that pelvic floor out just a little. Relax. That may have felt a little tricky to tighten some muscles and relax others at the same time. It is tricky at first – that’s why we’re practicing! Try it again. Deep breath in… and tighten your abs, keeping your pelvic floor and your glutes relaxed, letting that pelvic floor drop down.
At any time during pregnancy, you can practice those exercises separately, or practice coordinated pushing all together. That can help prepare you for second stage. But, even if you’ve practiced ahead of time, most people find that it takes a few pushing contractions to figure it out.
How long will pushing take?
For some people it takes minutes. For some it takes hours. The current obstetric guidelines are that for first time parents without epidurals, it may take up to three hours, or even longer may be appropriate as long as the labor is progressing. With an epidural, pushing typically takes longer than without one.
If someone wants to push more effectively, here are a few tips. First, ask the care provider if a different position, or an adjustment to your position, could make a difference. If there’s a lot of tension in the jaw, try unclenching the jaw and relaxing the mouth – somehow that helps with relaxing the perineum.
You may ask for a mirror so you can watch the pushing efforts – sometimes seeing the perineum bulge with a push can give a laboring person cues about how to push more effectively. It can also sometimes help for the laboring person to reach down and put their hand on their bottom so they can feel whether a push is effective.
Many women “hold back” during pushing. That is often due to fear. Sometimes if pushing is taking a long time, I’ll just ask “what are you worried about?”
Sometimes it’s something really big that she’s afraid to verbalize. But when she says it, we can start to move past it. For example, when I asked one person what she was scared of, she said “I’m afraid I’m going to be a crappy mom, because my mom was a crappy mom.” All I could do was validate “Wow… that would be scary. But I know that just the fact that you want to be a great mom is a great first step! And you know what, you’re going to have days you’re a crappy mom because we ALL have those days. But I’m pretty confident that in the long run you’ll have more good days than bad because you know how important it is. Let’s get that first good day started, OK?”
Sometimes they’re worried about relatively smaller issues. Many people worry they’ll poop in labor… after all, I said the urge to push feels a lot like the urge to have a bowel movement. Here’s the thing… not everyone poops while pushing… but it is not at all unusual for it to happen. If it does, the care providers clean it up, and then move on – it ‘s not a big deal for anyone. So try not to worry about it – just focus on pushing the baby out.
Other people worry that they’ll tear while pushing. You can talk to your care provider in advance about ways to reduce the risk – like good nutrition, pelvic floor exercises and perineal massage. And, during the pushing stage, remind the care providers about this concern and ask for suggestions. Changing positions can help. So can putting a warm compress (a warm washcloth) on your perineum as you push. And listening to your care providers’ advice in the moment.
At the very end of the pushing stage, when baby’s head is passing through the vaginal opening, that’s called crowning. Many people experience a burning, stinging sensation which is often called “the rim of fire.” This is your body’s signal to slow down pushing for a moment to let the vaginal tissue stretch around the baby’s head. This sensation also causes a huge rush of endorphins which relieves the pain and puts you and the baby in a euphoric state right after birth.
The Moment of Birth
Once baby’s head passes through the vaginal opening, the shoulders and the rest of the body slip through and the baby is born!
The best possible place for a newborn baby to be is skin-to-skin with the person who just gave birth. So, ideally the baby is laid right onto their belly.
Shortly after birth, the umbilical cord will be clamped and cut. Research indicates that it is best to wait till the cord has stopped pulsing, or at least till one minute after birth before clamping and cutting. Ask your care provider what their practice is and learn more about delayed cord clamping online.
The caregivers do a quick assessment of the baby’s condition, called the Apgar score, where at one minute and five minutes, they assess the baby’s heart rate, breathing, muscle tone, reflexes and skin color. If all appears to be well, the baby would stay right there. If there were concerns, then sometimes the baby might be taken to a warming station in the room or to a special care nursery. A partner or family member can go with the baby. If they are separated from the birthing parent for a while, they should remember to take pictures, and think of important memories to share when they are reunited.
Contractions continue, but they are much less intense than during labor and birth. These contractions help the uterus to shrink down, which causes the placenta to be released from the walls of the uterus, and then the placenta will be delivered – it may require a few pushes to deliver it.
Although much of the attention is on the newborn during this third stage, the birthing person still will benefit from “labor support” using relaxation, breathing, or other comfort techniques to manage the discomfort. Third stage typically takes 10 to 30 minutes. Typically, a dose of Pitocin is given to encourage the uterus to contract more quickly and to reduce bleeding.
During third stage, the care provider will also check to see if there were any tears and if there were, do stitches to repair those. A local anesthetic is given if needed.
The Golden Hour
Baby’s first hour is often called The Golden Hour. Right after birth, the baby and the birthing parent are flooded with oxytocin – the love hormone – and endorphins – which create euphoria and a sense of interdependence. The birthing parent is producing prolactin, often called the mothering hormone, as it creates a strong urge to protect and care for the baby. These hormones also influence the other people in the room, especially the other new parent. These hormones lay the foundation for bonding, and can be enhanced by anything that helps create an environment conducive for bonding such as dim lights, quiet music, and as few interruptions as possible.
If the birthing parent had pain medication, or had a cesarean, those can reduce the production of those hormones. However, getting the baby skin to skin on the birthing parent as soon as possible helps to re-build the supply.
Newborn babies benefit greatly from skin-to-skin time. That means the baby is bare, and the parent’s chest is bare, and there’s a blanket over both to keep them warm. This will help the baby regulate their breathing better, keep their temperature steady, and their blood sugar more stable. The catecholamine rush of labor also means the baby is alert and has a heightened response to touch and smell. All that helps them connect to their parents.
A newborn will do well on any adult caregiver, but it is ideal if the baby can be skin to skin with the parent who just gave birth. Breastfeeding in that first hour increases oxytocin flow, which reduces postpartum bleeding, and increases prolactin which will help the breast milk increase in volume more quickly.
For the first half hour or so after birth, the baby tends to be wide awake but calm. This is a perfect time for any rituals that are important to your family, such as naming the baby, saying a prayer, or singing a special song. This is a time to be focused on each other – your birth announcements on Facebook and Instagram can wait just a little longer.
By 40 – 45 minutes after birth, many babies (though not all) initiate a breast crawl – wiggling and squirming their way toward the breast. When they reach it, they may lick at the nipple, or massage it. Then they may latch on and begin to nurse. If a baby self-attaches, that improves breastfeeding success.
Not all babies get there on their own. If the baby has not latched on and begun to nurse by about 50 minutes, ask for support from a nurse or midwife to help baby get started.
If a baby is born by cesarean, that can interrupt this process. Try to create as much of this golden hour as possible in the operating room as the surgery is being completed. In some OR’s, the other parent or family member can hold the baby. Sometimes the baby can be on the birthing parent’s chest or even breastfeed as the surgery is continuing. If a cesarean seems likely for you, talk to your care provider in advance about ways to enhance this first hour after the birth.
[Watch this video on the benefits of keeping baby with you in the first hour after birth. Or read this article about the benefits of an undisturbed first hour.]
At the end of that first hour, after the first feeding, the baby can be weighed and measured, the vitamin K shot and eye ointment given. The baby then will typically be very sleepy. This is a great opportunity for the new parents to do some self-care – maybe a shower or a meal. If family is visiting, they can hold the sleeping baby for a while so everyone can recover from all the excitement of the birth. Over the next 24 hours, it is helpful for the baby and the birthing parent to have as much skin to skin contact as possible with the baby nursing whenever it shows hunger cues, which include sucking motions, licking its lips or rooting – turning the head side-to-side in search of somewhere to latch on and nurse. (Learn more about baby’s first feed.)
Resources for Parents:
- video on the benefits of keeping baby with you in the first hour after birth
- Poster of positions for pushing: http://betterbirths.rcm.org.uk/resources/rcm-products/positions-for-labour-and-birth-poster
- Video of positions: https://www.youtube.com/watch?v=AaOvPJsHonQ
- Video of positions with an epidural https://www.youtube.com/watch?v=j_qU6QL3NO0
Resources for childbirth educators
- Five Steps to Teaching Students How to Push Out Their Babies: https://www.scienceandsensibility.org/blog/how-to-push-a-baby-out
- The Evidence on Birthing Positions https://evidencebasedbirth.com/evidence-birthing-positions/ and https://www.lamazeinternational.org/p/cm/ld/fid=87
- WHO Recommendations for Intrapartum Care, 2018, http://apps.who.int/iris/bitstream/10665/260178/1/9789241550215-eng.pdf?ua=1
- Approaches to Limit Intervention during Labor & Birth. ACOG, https://www.acog.org/-/media/Committee-Opinions/Committee-on-Obstetric-Practice/co766.pdf?dmc=1&ts=20190326T2022537665