The First Stage of Labor
The first stage of labor is the longest stage of labor and is divided into two separate parts: early labor (latent labor) and active labor. During this first stage of labor, oxytocin is released by the brain, causing contractions that help to dilate (open) and efface (thin) the cervix.
Early (Latent) Labor
During early labor, contractions begin and the cervix begins to dilate and efface. During early labor, the cervix will dilate to 3-4 centimeters.
In early labor, these contractions may range from mild to moderate and can be as often as every three minutes, or as few as every twenty minutes, lasting anywhere between 10 and 40 seconds each.
A string of blood tinged mucous may pass. This is known as “bloody show” or the “mucous plug.” For the last nine months, the mucous plug has remained in the cervical canal acting as a protective barrier between your baby and the outside world.
The bag of waters may break during this stage, however, it is not uncommon for them to remain in tact much longer.
At this point, the mother may appear still “together” and is generally able to talk through her contractions. Early labor can last as short as half an hour in some women, to a few days in other women. There is no true way to predict the length of the early labor phase.
If the woman is uncomfortable, it may help to take a warm bath, however, if her bag of waters have broken, she should speak with her caregiver before bathing. Slow deep breathing, massage, and gentle music may help to relax her. She should be encouraged to sleep if at all possible, as she will need the energy for active labor.
During active labor, contractions become more intense and more regular lasting 60 to 80 seconds each and occurring every two to ten minutes. The contractions intensify as they work on the cervix to dilate even further to 4 to 7 centimeters. The contractions are much more painful and closer together at this point.
It is not uncommon for a woman to vomit when in active labor. The mother may seem more focused on her contractions, and working harder on focusing on them. By the time she has reached five or six centimeters, she may begin to make more noise and begin to rock or sway her pelvis. Around seven centimeters, she may be more inwardly focused and have extreme difficulty answering questions. Conversation and noise can be incredibly distracting and even irritating to her at this point.
It is important to remember that just as the primitive brain controls sleeping and sexual intercourse, it also controls birth. Things like talking, bright lights and being observed may inhibit the woman’s body from producing the hormone levels she needs to in order to achieve a normal, natural birth.
During active labor it may be helpful to sit on a birthing ball, take a warm shower or bath, go for a walk or get a massage between contractions. It is important that when trying new comfort measures during active labor that the woman tries it for at least three contracts before deciding if it is helping or not. Many times, moving from one position or activity to another can cause discomfort, but by the third contraction of doing something, the woman should be able to tell you if it is helping or not. Do not be surprised if something that was helping, suddenly becomes the last thing the woman wants. A laboring woman’s preferences may change rapidly and suddenly.
Transition is part of the active stage of labor. By transition, the woman’s cervix is dilated between 8 and 10 centimeters. Contractions are the strongest and last for 90 seconds every two minutes. The gap between the contractions is just barely long enough for the woman to catch her breath and start again. It is at this point that the waters usually break on their own. This stage can last anywhere from a couple of minutes to as long as an hour.
Transition is often the point where women start to lose faith in themselves and begin to tell others around them that they “can’t do this.” It is not uncommon for women to want to give up at this point. If the woman hasn’t already received pain medications, it is common for them to be requested at this point.
Transition is the more easily recognized part of labor for many reasons. When in transition, the woman may feel an urge to push. Visibly, her legs may shake, her feet may get cold. She may be nauseous and even vomit. She may suddenly become very cold. Some women even hiccup during transition. She may become angry, irritable and aggressive during transition. She may not want to be touched, and may remove all of her clothing and may not care what she looks like to others.
You may be able to see changes in the woman’s feet when she is in transition. Her toes, while contracting in transition, will usually curl deeply inwards. Another sign of transition may be observed in the back if the woman is upright or in a position where the lower back is visible. As the baby descends lower into the pelvis, a thin dark line will appear beginning at crack of the buttocks and will continue to get longer until it reaches 4 to six centimeters. If you place your hand on her lower back, you may be able to feel her sacrum move outwards as the baby continues to move downward.
Although this doesn’t always happen, in many women labor will appear to stop completely. This allows the woman to take a short break to breathe and relax. This phase can be non-existant, or last as long as an hour or more. By this point, she is likely very exhausted and having something to drink may help her.
Second Stage of Labor:
By this point, the cervix is completely dilated to ten centimeters. The direction of contractions changes as they begin to push the baby down through the birth canal. The contractions will now last 60 to 90 seconds and happen every two to five minutes. With each contraction, the baby is pushed further down the birth canal, and at the end of the contraction, the baby slips slightly back up the birth canal. As the baby stretches the mothers tissue in the birth canal, the mothers body responds by producing more oxytocin which then creates stronger contractions. This is known as Ferguson’s reflex.
On average, the second stage of labor lasts 1-2 hours for the first baby, and less than an hour for subsequent births. The woman’s previous births were cesareans, her second stage may resemble the second stage of a first time mother.
Once the baby’s head reaches the pelvic floor it needs to rotate into the correct position to allow it passage through the pelvis. The widest part of the head (front to back) must line up with the widest part of the pelvic outlet (front to back) before beginning to descend. Once descending, the pelvic floor offers resistance that results in the head turning into the correct position. This is referred to as internal rotation. As the head moves, there is no longer any resistance from the pelvic floor and extension takes place. Now, the baby’s head must rotate to line up with the shoulders. This is called external rotation. The baby’s shoulders are then born, one at a time and expulsion takes place when the baby is born.
Third Stage of Labor:
The third stage begins at the birth of the baby and ends at the expulsion of the afterbirth and placenta. Depending on the mother and her caregiver, the third stage of labor can be actively managed, or expectantly managed.
In an actively manages third stage, the caregiver will provide the mother with a dose of an oxytocic drug, such as pitocin, into her thigh or through an IV drip. Oxytocic drugs create strong contractions. After the birth of a baby, contracts help to separate the afterbirth from the uterine wall and help to prevent postpartum hemorrhage of more than 500ml of blood. In addition to the drugs administered, the baby’s cord will be clamped and cut immediately following birth. This is to prevent the baby from getting too much blood from the placenta as the oxytocic drugs begin to take effect. The caregiver will then apply external pressure to the top of the mother’s uterus (the fundus) and may then gently tug on the umbilical cord to help encourage the placenta to separate from the uterine wall.
In an expectant third stage of labor, no interventions are used. Once an intervention is used, it is no longer considered an expectantly managed third stage. An expectant third stage allows the mother’s body to naturally, at its own pace, expel the placenta and afterbirth. The baby is born, and passed straight to the mother with the cord still attached, unclamped, and uncut. This stage may happen faster if the mother is skin to skin with her baby, and breastfeeding, as the release of oxytocin from breastfeeding causes the uterus to contract which encourages the placenta to separate from the uterine wall.
Cord traction and fundal pressure should never be used in a natural third stage. If it is used, it may result in the cord snapping and a retained placenta, or uterine prolapse (the uterus is pulled down causing injury). If cord traction and fundal pressure is to be used, oxytocics should be administered first.