Stages of Labour

Importance of Physiological Labour
Labour and birth is an important, natural, healthy and life changing event. Be informed so you can make decisions to have the best birth for you. According to the World Health Organization (1996),

“The aim of care [during labour and birth] is to achieve a healthy mother and child with the least possible level of intervention that is compatible with safety. This approach implies that: In normal birth there should be a valid reason to interfere with the natural process."[REF-491]

In a recent update to the above guideline, the World Health Organization (2018) recognizes:

"a 'positive childbirth experience' as a significant end point for all women undergoing labour" and that it's important "to have a sense of personal achievement and control through involvement in decision-making, even when medical interventions are needed or wanted."[REF-4nu]

There is emerging evidence that allowing labour to unfold on its own, without unnecessary intervention, has many potential health benefits for both mother and baby, including:

• Early and increased attachment and bonding with your baby[REF-4lp]
• Easier start to breastfeeding and longer duration[REF-4lp]
• Better physical wellbeing in the first 3 months⁸
• Less risk of perinatal mental health disorders in the first 3 months⁸ [REF-4si]

How Labour Progresses

The last few weeks of pregnancy are an important time for your body to prepare for the work of labour and birth. It's important that you don't rush the beginning of labour unless there are medical reasons. During this time, your labour hormones are preparing for labour and birth, breastfeeding and bonding to unfold in an optimal way. Remember that each labour is unique and will unfold at it's own pace. Labour progresses through 4 stages.

Stage 1: Three Phases (Early/Latent, Active, & Transition)

Stage 2: Pushing & Birth

Stage 3: Birth of your Placenta

Stage 4: Skin-to-skin Transition After Birth

Stage 1: Three Phases

Begins when you start to feel contractions and ends when your cervix is fully dilated at 10 centimetres. The length from active phase (5 cm) to full dilation for first time mothers is usually is no longer than 12 hours.[REF-4nu] Following births are usually shorter.[REF-4nu]

1. Early/Latent Phase

• Contractions are far apart, short in length, and less intense than they will be later on.
• The cervix begins to move more anterior (lining up with the vagina), efface (become thinner) and dilates from 0 to 4⁵, 5[REF-4nu] or 6⁶ cm.
• You may feel excited and nervous as labour begins.
• The usual length of this phase is unknown and can vary widely from one individual to another.[REF-4nu] It may last for days and may stop and start again.
• It helps to move around, drink, eat healthy snacks, and rest during this phase.
• It's best to stay home until you are in the active phase of labour.[REF-4nu]
• If all is going well, it is best to avoid medical augmentation of labour during this stage.[REF-4nu]

2. Active Phase

• Contractions start to become more regular, come closer together, last longer, and become more intense.
• The cervix continues to thin and dilate from 5 to 8 cm.
• You may feel tired and anxious or you may feel excited in anticipation of seeing your baby.
• You may experience some back pain from the pressure of your baby’s head sitting in your pelvis.
• This is often the phase when women will rely heavily on their support system and may ask for pain medication.

3. Transition Phase

• Contractions come every 2-3 minutes and last 60-90 seconds.
• The cervix dilates fully from 8 to 10 cm and your baby starts to descend into the birth canal.
• You may feel restless, irritable, and overwhelmed by the intensity of this phase but remember this is the shortest phase of labour.
• During this phase labour is changing from stage one (effacement and dilatation) to stage two (pushing).

Stage 2: Pushing & Birth

Begins when your cervix is fully dilated and ends when your baby is born. The pushing stage is usually not longer than 3 hours for first time mothers.[REF-4nu] Following births are usually shorter.[REF-4nu]

• You will enter the second stage of labour (pushing) when your cervix is fully dilated to 10 cm. Some women feel an intense, instinctive urge to push while others may not experience this sensation. Bearing down with contractions helps to move your baby through the birth canal. Some women experience a period of no contractions (rest and be thankful time) before the urge to push occurs. This is normal and allows you to rest for the work of pushing. Take advantage of this rest time.
• There is no “right or wrong” way to push. However, upright, squatting or forward leaning positions tend to work with gravity and can better assist your baby to navigate down and through your pelvis. It is important to discuss your preferences for the second stage of labour with your healthcare provider prior to labour beginning. You should be supported in your choice of birth position.[REF-4nu] Never practice pushing during pregnancy.
• When women push naturally (without any instructions) and based on their own instinctual rhythm, they tend to do three to five short pushes during each contraction. As the second stage of labour moves along, the number of pushes per contraction tends to increase. With natural pushing, women take in several big breaths of air with each pushing effort, and slowly blow all the air out of their lungs. Studies show that the natural way of pushing allows the most oxygen to reach your baby during the second stage of labour. ¹
• The best success is accomplished if you push when you have the urge to push. You should be encouraged and supported to follow your own urge to push.[REF-4nu]
• You can also lie on your side for pushing. This position helps to bring about a slower birth and the fewest perineal (the area between the vagina and the rectum) tears. If you are tired, a side-lying position will also allow you to rest in between pushing efforts.
• When your baby reaches the lower/outer opening of your vagina, you will be able to see/feel the top of their head during contractions. However, your baby’s head may slide back between contractions for a period of time and will then suddenly stay at the opening even in between contractions. This is called “crowning”. Most women experience an intense burning or stinging sensation during this time, as your baby’s head stretches the tissues. This is usually brief, lasting only one or two contractions and then your baby’s head will then be born. Their shoulders and then body are born quickly after this.
• Your baby will be immediately brought up onto your belly, dried and covered with a blanket. This is the beginning of your baby’s transition to life after birth with skin-to-skin care.

Perineal massage

Perineal massage (massage to assist with relaxation and stretching of the area between your vagina and anus) done regularly during the last 4-6 weeks of pregnancy has been shown to reduce the risk of tearing or need for an episiotomy during birth and less pain after.²
Perineal massage can be done by yourself or by your partner to prepare the tissues of the perineum by gently stretching them to help them become more elastic over time. It helps you to become familiar and practice coping with some of the sensations that you may experience when your baby is crowning. It also allows you to practice relaxing those muscles in preparation for the birth. It may also be done by your healthcare provider during stage 2 (pushing stage) of your labour and birth to gently stretch the perineal tissues. Discuss this procedure before labour to make an informed decision.
For more information and how to perform perineal massage please see: Journal of Midwifery & Women’s Health perineal massage resource

Stage 3: Birth of your Placenta

Begins after your baby is born and ends with the birth of your placenta.

• The birth of the placenta can take anywhere from five to 30 minutes.
• You may receive a dose of synthetic oxytocin (by injection or intravenous) to help your uterus contract and prevent excess bleeding as soon as the baby is born depending on the practice of your healthcare provider. Discuss this with them before your labour begins.
• Contractions may stop after the birth of your baby, and then start again.
• There may be a gush of blood before or during the delivery of the placenta.
• The placenta is delivered with a few spontaneous and mild contractions.
• Your healthcare provider or nurse may massage your uterus after the birth of the placenta to help contract the uterus and expel any remaining blood clots.
• The placenta, membranes, and umbilical cord are examined by your healthcare provider to make sure that the placenta is intact and ensure there are no remaining pieces left behind in your uterus.
• Your abdomen may be sensitive.

Stage 4: Skin-to-skin Transition After Birth

Stage 4 is the immediate skin-to-skin transition time for both mother and baby.¹. This is a very important time of bonding and breastfeeding initiation immediately after birth. Unless there are medical reasons, this time together skin-to-skin should not be interrupted until after your baby's first feeding. This can take anywhere from 1-2 hours after birth. Monitoring and care for both mother and baby can be completed while mother and baby remain together and should be limited to only essentials during this time. Visitors should wait until after this important transition time together.

Adapted / Reproduced with permission from Best Start by Health Nexus.