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Labor Initiation: Getting It Going
Introduction to Stages of Labor
Stage 2 of Labor & Birth: Pushing The Baby Out
Stage 3 of Labor & Birth: Delivery of the Placenta
Stage 4 of Labor & Birth: Immediately Postpartum
STAGE 1 OF LABOR
PHASE 1 (EARLY PHASE):
This first phase is also called the latent phase.
This early labor of stage 1 takes about 8 to 12 hours (average) if the woman has had one or more children (multipara) and about 16 to 18 hours in a woman expecting her first child (primipara). This part of labor can last much longer in some births and still be considered normal. Some women will experience start and stop labor over a period of several days before true labor finally starts and continues until the baby is born. Some women will experience the baby "dropping" (moving into the pelvis and the head engaging) before labor begins. Other women, most often first time moms, may not experience this until after the labor begins.
The cervix begins to efface and dilate up to 3 centimeters. True contractions begin. The contractions are rhythmic, squeezing muscular activity that affects the walls of the uterus during labor. These contractions last 15 to 30 seconds, up to 45 seconds each and occur every 10 to 30 minutes and may be almost imperceptible and come on an irregular basis. They become regular as time passes. The amniotic sac may or may not break at this early stage. The passing of the thick, blood-tinged plug of mucus (bloody show) that protects the mouth of the uterus during pregnancy will most likely occur at this point.
If a woman is planning a homebirth, this is usually when she should notify her midwife about her labor so the midwife can gather her supplies and begin her traveling plans to arrive at the birthing woman's home.
The midwife may offer phone support (if she lives nearby) and encourage the woman to relax, take a warm bath or shower, walk, eat a light meal (soup is a good choice), or even take a light nap during her early contractions to make sure she is fully rested for her next phases of labor.
Breathing exercises should be slow and relaxed. Some women may feel this as a slight nagging "backache" that tends to let up and then comes back.
Light labor occurring. Walking and relaxed, active movement
assists with productive labor.
If a woman is planning a birthing center or hospital birth, she should notify her midwife or health care provider about the beginning of her labor. This will be the time that she may want to spend at home, relaxed in her own environment instead of proceeding to the birthing facility.
PHASE 2 (ACTIVE PHASE):
This is the active labor phase.
Contractions grow stronger and start coming every 3 to 5 minutes and for a duration of 45 to 60 seconds each. The cervix dilates from 3 to 8 centimeters and is effaced close to 100%. The woman's breathing needs to stay as relaxed as possible during this phase, but she will, most likely, have to focus more on the contractions as they come and go. The woman should be at the location chosen for delivery (home, hospital or birthing center).
At a homebirth setting, the midwife would have usually arrived at the home during this time.
Observations by the midwife will be made regarding the frequency, duration and intensity of the contractions as well as the mother's ability to cope with the contractions. The midwife will give the woman encouragement and assist her and her partner with her breathing and relaxation techniques, offering suggestions and support for utilizing various alternative laboring techniques.
Mother working with labor using slow, relaxed breathing.
Her husband/partner is assisting her with her breathing and relaxation techniques.
An initial exam is made to determine how far the cervix had dilated and effaced, the extent of the engagement into the pelvis and position of the baby's head and its placement upon the cervix. Notation is made about the "bloody show" (the cervical mucus released as the cervix dilates).
The abdomen will be palpated (felt by the midwife's hands) to confirm the baby's body position and degree of engagement into the pelvis.
The baby's heart rate (fetal heart tones or FHT) will be monitored using a fetoscope (special stethoscope for hearing fetal heart sounds) and/or by using a doppler (an ultrasound monitor that sends out sound waves and picks up the echo of the fetal heart sounds). The location of the FHTs will also verify fetal positioning.
The fetoscope is great for picking up the intensity of the heart sounds while the doppler is helpful for amplifying the sounds that, sometimes, may be difficult to pick up with the fetoscope. The placenta sounds may be heard using either method (it is a whooshing sound as compared to the rhythmic thump-thump sound of the fetal heart). FHT frequency, intensity, rhythm variations during contractions and when the uterus is at rest is listened to by the midwife. The FHTs should be in the 120 to 160 heart beats per minute range throughout the pregnancy, labor and delivery.
Assessing fetal heart rate with an ultrasound stethoscope (doppler).
When the amniotic sac breaks, the midwife will note the color and amount of amniotic fluid. Green or brown fluid indicates the presence of meconium (fetal bowel contents) and its consistency. If meconium is present, extreme caution is taken during the birth to prevent the baby from aspirating it into the lungs. The normal color is clear, sometimes containing a little mucus and blood tinge to it.
The midwife will assess the mother by taking her blood pressure, pulse and respirations. Questions will be asked about her last bowel movement, urination (which needs to be done every few hours since a full bladder may inhibit contractions and slow labor) and last oral intake. It is normal for the mother to experience soft stools a few days or so prior to labor. It is nature's way of cleaning out the bowel to get it ready for the labor. If the mother has taken something to initiate labor (such as castor oil), she may experience diarrhea-like stools as she cleans her bowels.
Assessing the mother's vital signs.
It is very important for the mother to keep her energy up during her labor and prevent dehydration. Light meals and fluids are encouraged. Herbal teas, some specially helpful during labor, may be given to assist with nutritional and labor needs. I usually make up some MoonDragon's Pregnancy Tea, if the mother hasn't already made it and placed it in the refrigerator.
MOONDRAGON'S PREGNANCY TEA
2 parts Red Raspberry Leaves
1 part Nettle Leaves
1 part Alfalfa Leaves
1 part Peppermint Leaves
Mix well and use amount needed to make a strong tea. Ice cubes or ice chips can be made before hand out of this tea and kept in the freezer for labor. This tea provides excellent nutrition and energy for the mom, settles her stomach (nausea and vomiting can occur during labor) and makes a good base for adding labor tinctures to help with the labor, if needed.
Again, breathing and relaxation techniques are reinforced and reassessed. Effleurage (light massage on the pregnant belly) and other types of massage are helpful in relaxation. Warm baths or showers to help relaxation. Walking, standing, kneeling, laying on left side and other positions are frequently changed to assist with labor. If back labor becomes a problem (often seen with a posterior (baby's face to mother's pubic bone) positioned baby, counter-pressure may be used on the mother's lower back to reduce the discomfort. If the woman is planning on a waterbirth, the tub is prepared for use.
If the woman is giving birth in a birthing center or hospital setting, the woman and her partner will arrive at the facility. The midwife or health care provider will admit and orient the woman and her partner to the birthing unit. Introductions are made and the woman is assigned a room and bed. Hospital or birthing center procedures are explained to the mother and her partner.
In the hospital setting, assessments are made by monitoring the mother and baby, usually using a doppler and/or an electronic fetal monitor. An IV (intravenous drip of glucose [sugar water] often used for energy during labor) may be started on the mother in the event a cesarean delivery needs to be done and to keep the woman's fluids up in her body. It also allows the health care providers to inject medications directly into the IV. An enema, perineal prep (washing, shaving or clipping the pubic area) and other required procedures (varies with each facility) may be performed. Drugs (analgesic or a regional anesthetic) may be administered by an anesthesiologist. If the labor slows down or stalls (most often either due to drug administration or inability to move about, or both), then pitocin (synthetic oxytocin) will be given to speed the labor up again. Depending upon the facility, procedures used and the drugs administered, the woman may be confined to a labor bed for the duration of her labor or she may able to move around by walking, sitting, or changing birth positions. She may be given ice chips to prevent dehydration. Oral food and fluid intake is usually discouraged and prohibited in the event that a cesarean surgery and a general anesthesia is to be used.
PHASE 3 (TRANSITION PHASE):
This is the transitional phase of labor.
Transition is probably the most difficult part of labor and usually lasts about an hour, sometimes less, sometimes more. The cervix becomes fully dilated (10 centimeters). Contractions switch from the type that open the cervix to the "pushing-down" type meant to expel the baby.
Other symptoms may occur, such as nausea, vomiting, shivers and irritability. This is the time when a woman may have some feelings of self-doubt and feels that she cannot go on through the labor. A good supportive birthing team can aid in overcoming these feelings.
Breathing patterns may change. Sometimes a woman will get a "catch" in her breathing and this is a good indication that the labor has just switched gears into high gear. Some midwives say the birthing energy around the woman changes. The woman may be encouraged "not to push yet" by doing a rapid "panting" or "huffing" type of breathing if she has the pushing urge. This helps to delay pushing until the cervix is completely dilated and can slip over the baby's head. Sometimes the cervix may have a "lip", a small cervical area that has not thinned out and/or moved over the baby's head, usually caused by the mother staying in one position too long or in a position that didn't apply or keep pressure from the baby's head on the cervix during the contractions. The mother may be encouraged to change position (such as squatting in an upright position) to put direct pressure on the lip. The midwife may help guide it over the head using her fingers during a contraction (it can be a little uncomfortable for the mom, but it allows the baby's head to slide past the cervix and into the birth canal). At home, we want to make sure she is fully dilated so we don't have any cervical tears.
If the woman is giving birth at home, the midwife will prepare the mother to give birth by changing her position to the birth position of the mother's choice and doing a quick vaginal check to make sure that complete dilation has occurred and that the cervix has cleared the baby's head.
Performing a vaginal exam to determine
cervical dilation and effacement
Focusing, relaxation, encouragement and support are reinforced. The woman may be encouraged to continue with slow breathing patterns as long as she is able to do so and use the panting (rapid breathing) only if she feels the urge to push before she is ready to push. Pushing should be done only after complete dilation is achieved and the cervix has slipped over the baby's head... pushing to soon can cause the cervix to swell and the dilation to regress, slowing down the labor and birth process.
Transition phase. Dilation check has been done.
Cervix has completed dilation & effacement.
Stage 2 of labor is beginning.
If the woman is giving birth in a hospital or birthing center, she may have to be transported to the delivery room or area. Drugs may be administered and the birth team organized. Final preparations are readied.
NOTIFY YOUR MIDWIFE OR HEALTH CARE PROVIDER IF...
You or a family member has questions or concerns about labor and delivery.
If you are in labor and you need to contact your birth team (midwife or health care provider).
If you have any unexpected or unusual signs or symptoms and need emergency transport during labor.
Labor Initiation: Getting It Going
Introduction to Stages of Labor
Stage 2 of Labor & Birth: Pushing The Baby Out
Stage 3 of Labor & Birth: Delivery of the Placenta
Stage 4 of Labor & Birth: Immediately Postpartum
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MoonDragon's Pregnancy Information: Pregnancy Information & Survival Tips
Some photos obtained from "Attending Ob/Gyn Patients" Nursing Photobook by Nursing Books, Intermed Communications, Inc.
