The day you’ve been waiting for is finally here. It’s time for the most important journey your baby will make, from the safety of the womb to the world. Now is when all your preparation will pay off. It’s important to understand the birth process and the unexpected turns that may be ahead.
When Does Labour Start?
The normal time for labour to start is between 37 and 40 weeks gestation. There are a couple of ways you will know that labour is starting. You may have been having painless and irregular contractions on and off for the last few weeks. These are known as Braxton Hicks contractions and are the womb practising for labour. Usually they come and go. They are regular for a couple of hours and then die away and they can be quite uncomfortable. The difference with this and true labour, is that labour contractions become regular and usually build. The intensity of how often they come and their strength and how painful they are increases.
If you have had regular painful contractions every 10-15 minutes, or more often for a few hours, consider contacting your obstetrician.
Sometime labour starts with a “show” which is when the mucus plug comes away from the cervix. The mucus may even be streaked with some blood. If there is more than a streak of pink blood in the mucus it’s important to contact your obstetrician. The mucus plug may come away a few days before contractions start. Or with the first few painful contractions.
Any actual bleeding is a worrying sign and you should always contact your obstetrician about this.
Your baby is in a bag of amniotic fluid, known as the membranes. Sometimes the membranes rupture before labour or at the start of labour. If this happens you will experience a sudden gush of fluid which feels a bit like urine coming away from you. But you won’t have any control over this. This fluid should be clear like urine. If it is blood stained or a greenish colour, contact your obstetrician. Sometimes the membranes don’t rupture on their own and need to be broken with a small hook during a vaginal examination in labour.
If you develop signs of labour or lose clear fluid from the vagina before 37 weeks, you are at risk of preterm birth. Contact your obstetrician right away.
First Stage of Labour
This is when the cervix (neck of the womb) goes from being closed to fully dilated (10cms dilatation). Initially, this process can be slow and may take a few days of contractions on and off as the cervix softens. This is called the latent phase. Even though the cervix may not be opening, these contractions can still be quite painful. It can disrupt sleep so it’s important to get some rest when you can, but try to stay mobile when you are wake.
Once the cervix reaches 3 cm dilated, this is usually classed as the proper start to the first stage. The minimum progress in labour is 0.5 cm per hour so vaginal examinations are usually done every four hours. If progress is slower than expected, your obstetrician may recommend an intravenous drip containing a hormone called oxytocin. This is to increase the power of the contractions and speed up labour.
Your baby’s heart rate will be monitored throughout labour. This is with a heart monitor called a CTG (cardiotocograph). Some heart rate patterns can suggest the baby may not be coping with the stress of labour. If this is the case plans may need to change to consider if a caesarean birth would be safer for the baby.
Second Stage of Labour
This stage is divided into two phases, transition and delivery. Once the cervix is fully dilated, your baby’s head needs to descend through the pelvis on to the pelvic floor muscles. This is the transition phase. As the head descends, it dilates the vaginal walls and rotates so that the back of your baby’s head (the occiput) is facing up towards the mother’s pubic bone. This stage can take up to an hour, particularly if the woman has an epidural for pain relief. Sometimes the contractions ease off at this stage and your obstetrician may recommend an oxytocin drip if this happens.
Once your baby’s head reaches the pelvic floor muscles this triggers powerful contractions and an urge to push. Your midwife or obstetrician will guide you at this stage. It’s usually most effective to take a deep breath and then hold it in while pushing. You should be able to give two to three long pushes in each contraction. It’s important to push in the correct place. It’s the sensation of opening your bowels rather than pushing in the vagina (don’t worry you won’t open your bowels – it’s just the sensation of the baby’s head pressing on your rectum). Once the head is delivered your obstetrician will check there is no umbilical cord round your baby’s neck. Then with the next push your baby should be born.
It is usually advisable to wait to clamp the cord until it has stopped pulsating. This usually takes a minute or so while your baby is being dried. The paediatrician will make an assessment of your baby’s condition. Unless they have any concerns, they will encourage skin-to-skin as soon as possible.
Third Stage of Labour
The third stage is when the placenta is delivered. It is advisable to have active management of this stage to minimise blood loss. The midwife will give you an injection of oxytocin into your leg as the baby is delivering. You probably won’t even notice this. This encourages the womb to contract which causes the placenta to separate and then with gentle traction on the umbilical cord, the placenta is delivered. Some women worry about having the injection as it can sometimes cause nausea. Studies have shown that having a natural third stage increases blood loss and increases the chance of needing a blood transfusion by threefold. This is a case where most of the time the benefit outweighs the possible side effects. If you would prefer a natural third stage, discuss this with your medical team well before the day.
We don’t understand why labour is painful. It doesn’t seem to affect the birth process or the baby in a positive way but the pain can be exhausting and distressing for the mother. It’s impossible to predict how painful or not labour will be so it’s advisable to keep an open mind about pain relief. Some women find it helpful to have attended hypnobirthing and yoga training during pregnancy. They can use those techniques to reduce the pain sensation.
The simplest and most flexible pain relief is Entonox. Also known as gas and air. This is a mixture of oxygen and nitrous oxide breathed in through a mouthpiece held by the woman so she can have as much or as little as she needs. This is only used once labour is established.
An alternative is a painkilling injection of pethidine or morphine. This can be given by injection into the leg or buttock during the first stage of labour and even the latent phase if necessary. It is effective but shouldn’t be given if delivery is expected within 4 hours as it can cross the placenta and affect the baby’s breathing.
An epidural is a very popular choice of pain relief. A small plastic tube is placed into the space in the spine outside the spinal cord and provides a numb feeling from the waist down. While it provides effective pain relief it does make it difficult to move around and increases the chance of needing an assisted delivery.
Complications of Labour
Sometimes labour goes slower than expected. Often this is because the womb isn’t contracting efficiently. This can be corrected with the oxytocin drip as mentioned above. Sometimes slow progress is because your baby isn’t in the streamlined position or because it’s too big for the birth canal. In these circumstances your baby may need to be turned into the correct position or a caesarean section may be needed.
Your baby may become distressed during labour. This can be detected from specific patterns on the heartrate trace (the CTG). Or if your baby has opened its bowel and passed meconium which stains the amniotic fluid green. This might mean that your baby needs to be delivered, either by ventouse or forceps if the cervix is fully dilated, or by emergency caesarean section.
If the second stage of labour isn’t progressing the woman may need a ventouse (vacuum) or forceps delivery. This involves putting the woman’s legs up in stirrups and helping the baby’s head to come down while the woman continues to push as well as she can. It may be necessary to make a cut to the vaginal opening and pelvic floor muscles. This is known as an episiotomy, which helps the delivery. But more importantly significantly reduces the risk of damage to the anal sphincter muscles.
Occasionally, there can be heavy bleeding during or after the delivery. This might be due to the placenta not separating fully, or bleeding from vaginal tears or an episiotomy. This may mean extra drugs need to be given. You might need a drip in your arm or might even need to be transferred to the operating theatre. Some women have a religious objection to blood transfusion. If that is the case for you it is vital that you have discussed this with your obstetrician well in advance of the delivery.
It is important to remember that things can change very quickly in labour. There may not be lots of time to consider all the options. This is why it is so important to have developed a relationship of trust with your obstetrician. Know you are both working together for the shared goal of a safe delivery of a healthy baby to a healthy mother.