Pregnancy – labour

Labour is divided into 3 stages. The first stage is the dilation of the cervix, the second stage is the birth of the baby, and the third stage is the delivery of the placenta. For first-time mothers, labour takes around 12 to 14 hours. Women who have undergone childbirth before can expect about 7 hours of labour.

Recognising the start of labour

Braxton-Hicks contractions are sometimes mistaken for labour. These ‘false’ contractions usually start halfway through the pregnancy and continue all the way through. You may find these contractions visibly harden and lift your pregnant belly.

It is not known what triggers the onset of labour, but it is thought to be influenced by the hormone oxytocin, which is responsible for causing uterine contractions.

Symptoms of going into labour

Some of the signs and symptoms of going into labour may include:

• period-like cramps
• backache
• diarrhoea
• a small bloodstained discharge as your cervix thins and the mucus plug drops out (this is called a ‘show’)
• a gush or trickle of water as the membranes break
• contractions.

First stage of labour

The first stage of labour involves the thinning of the cervix and its dilation to around 10 cm. The first stage is made up of three different phases:

• The latent phase – Generally, this stage is the longest and the least painful part of labour. The cervix thins out and dilates zero to three centimetres. This may occur over weeks, days or hours and be accompanied by mild contractions. The contractions may be regularly or irregularly spaced, or you might not notice them at all.
• The active phase – The next phase is marked by strong, painful contractions that tend to occur three or four minutes apart, and last from 30 to 60 seconds. The cervix dilates from 3 to 7–8 centimetres.
• The transition phase – During transition, the cervix dilates from 8 to 10 centimetres (that is, fully dilated). These contractions can become more intense, painful and frequent. It may feel as though the contractions are no longer separate, but running into each other. It is not unusual to feel out of control and even a strong urge to go to the toilet as the baby’s head moves down the birth canal and pushes against the rectum.

Throughout the first stage of labour, careful monitoring and recording of your wellbeing and that of your baby, and the progress of your labour, is important. This is to ensure that labour is progressing normally and that any problems are recognised early and well communicated.

Second stage of labour

The second stage of labour is from when your cervix is fully dilated to the time your baby is born. The contractions during this time are regular and spaced apart. As each contraction builds to a peak, you may feel the urge to bear down and push. The sensation of the baby moving through the vagina is described as a stretching or burning, particularly as the baby’s head crowns (appears at the vaginal entrance).

At the time of birth, a doctor or midwife may guide your pushing to enable a gentle, unhurried birth of your baby's head. Sometimes the umbilical cord is wound around the baby's neck. If possible, the doctor or midwife will loosen it, loop it over your baby's head, or clamp and cut it to allow your baby to be born safely.

Once the head has emerged, your midwife or doctor will guide your baby’s body so the shoulders come out. The rest of the baby will then follow.

If this is your first baby, the second stage of labour can last up to 1 to 2 hours, particularly if you have had an epidural. If you have had a baby before, this stage is often much quicker.

Monitoring of your condition and that of your baby is increased during the second stage of labour. A long second stage of labour can result in risks for you and your baby. If your labour is not progressing, it is important that the reason is worked out and steps are taken to help you.

Third stage of labour

After the birth of your baby your uterus gently contracts to loosen and push out the placenta, although you may not be able to feel these contractions. This may occur 5 to 30 minutes after the birth of your baby.

The muscles of the uterus continue to contract to stop the bleeding. This process is always associated with a moderate blood loss – up to 500 ml.

In this stage of labour, one of the potential problems is excessive bleeding (postpartum haemorrhage), which can result in anaemia and fatigue. This is why the third stage is carefully supervised.

There are two approaches to managing the third stage:

• Active management – this is the common practice in Australia. After the birth of your baby, the midwife or doctor gives you (with your consent) an injection of oxytocin, clamps and cuts the umbilical cord, and then carefully pulls on the cord to speed up delivery of the placenta. Active management has been found to reduce excessive blood loss and other serious complications.
• Expectant management – the placenta is allowed to deliver on its own, aided by gravity or nipple stimulation only. In this approach the umbilical cord stays connected to the baby until the cord stops pulsating.

Monitoring your baby during labour

During labour, your baby's heart rate will be checked regularly. If you have had a low risk pregnancy and there are no problems at the onset of labour, your baby's heart will be listened to every 15 to 30 minutes using a small hand-held Doppler ultrasound device or Pinard (fetal stethoscope). This equipment can be used regardless of the position you are in.

If you had problems during pregnancy or if problems arise during your labour, your baby’s heart rate may be monitored continuously using a cardiotocograph (CTG).

A CTG involves having two plastic disks (receivers) strapped to your abdomen and held in place by two belts. The receivers are attached to a machine, which may limit your movement. Some hospitals have machines that enable you to move around freely while you are being monitored. This is known as telemetry.

Care of the perineum during birth

The area between the vagina and anus is called the perineum. Once the baby's head starts to crown (appear) the perineum will tear if it can't stretch enough. These naturally occurring tears can be difficult to stitch and may not heal very well. In around 3–4 per cent of cases, the vagina tears right through to the anus.

An episiotomy is an intentional cut of the perineum, using a pair of scissors. This clean cut is much easier to control and repair, tends to heal better than a tear, and is less traumatic to the underlying muscle and tissue. An episiotomy may be needed during the last part of the second stage of labour if:

• the birth needs to be quicker if you or your baby show signs of distress
• you need an assisted vaginal birth
• you are showing signs that you may tear badly.

If you are having your first baby, you may help prevent tearing by massaging the perineum during the weeks prior to the birth. Massaging the perineum during the second stage of labour has not been shown to stretch tissues and therefore does not reduce perineal injury.

Episiotomies should be performed only if needed. They should not be 'routine' as they do not reduce the risk of severe perineal injury, urinary stress incontinence or trauma to the baby.

Suggestions for preparing for labour

Some women may find the following activities helpful in preparing for labour:

• choose your support person – someone you are comfortable with and who will help you rather than distract you during the different stages of labour
• yoga
• relaxation exercises
• hypnotherapy (a state of relaxation)
• childbirth education – for you and your support person.

Early stages of labour

Be guided by your doctor or midwife, but general suggestions for a woman approaching labour include:

• Once you go into early labour, take the opportunity to rest and relax at home. There is no need to be in hospital until the contractions are regular and painful.
• Call your support person to let them know your labour is beginning.
• Once the contractions are around 7 to 10 minutes apart, start timing them. Do this by noting how many minutes elapse between the start of one contraction and the start of the next.
• If you are unsure whether to stay home or go to the hospital, ring and speak to one of the midwives. They will ask you a number of questions and help you decide what to do.
• Once your contractions are 5 minutes apart, or if you live a long distance from the intended place of birth (often the hospital), or if you no longer feel comfortable being at home, go to the intended place of birth.
• If your waters break or if you start bleeding from the vagina, go immediately to hospital.

Once you are in your intended place of birth

Suggestions for labour once you are in your intended place of birth include:

• Drink plenty of fluid (water, juice or iceblocks).
• Suck on sweets to keep up your energy.
• Vary your position to keep as comfortable as possible (standing, kneeling, lying down, straddling a chair, or on all fours).
• Have a bath or hot shower.
• Ask your support person for a back rub or massage.
• Try to relax between contractions.
• If you need or want it, discuss having some pain relief.
• Resist any urge to push until your cervix is fully dilated (your midwife will let you know when this has occurred).
• The pressure of your baby’s head helps to widen your cervix, so use gravity and walk around, stand or sit upright.
• Don’t feel embarrassed or inhibited by your appearance or behaviour – your midwife has seen it all before. If you want to grunt, yell or swear – go ahead.
• Remember that passing a bowel motion during labour is normal and nothing to be concerned about.

Having a support person

Having a support person with you can help enormously during labour. Your support person can:

• encourage you
• give emotional support
• help to make you comfortable
• help with breathing techniques
• provide ice to suck if you are thirsty
• provide a heat pack for your back or a cool face washer for your forehead
• massage your back
• celebrate the arrival of your baby with you.

Where to get help

• Your GP (doctor)
• Your hospital or birth centre
• Obstetrician
• Midwife