Stages of Labor

Labor

It's important that the healer be able to distinguish between true labor and false labor. In most cases the healer can pinpoint true labor by looking at the cervix. If the contractions aren't comfortable, are irregular, are affected when the patient changes her activity, and don't last more than 45 seconds, then she's probably experiencing false labor. True labor contractions become stronger, last longer, and get closer together as the labor progresses. This affects changes in the cervix, causing it to thin out and open while encouraging the descent of the baby through the pelvis. Following are some quick tests:

True Labor

• Contractions are felt more in the back.
• Contractions become strong, longer, and closer together over time.
• Bloody or pink show is present.
• An activity change or warm shower increases the intensity of the contractions.

False Labor

• Contractions are felt more in the abdomen.
• Contractions don't change in intensity - even though they're sometimes strong and close together.
• There's no bloody show.
• An activity change or warm shower usually decreases the intensity of the contractions.

The following are signs that labor has indeed begun. They can occur in any order:

Contractions: Contractions will get longer and closer together as labor moves ahead. The healer will notice that the contractions are regular and tend to follow a pattern. If the patient continues to have contractions that have no rhythm, but are five to seven minutes or less apart, call a master midwife immediately.

Rupture of Bag of Waters: This breakage of the membranes surrounding the baby could result in a flush or an uncontrollable leakage of fluid from the vagina. The fluid is colorless and odorless. In most cases, the contractions will begin six to 12 hours following the rupture of the sac. The patient should notify a healer as soon as the membranes rupture or the bag of waters break.

Early Signs

Following are some signs that will show that the patient might be heading toward labor. Some signal that labor is imminent; others will surface days or even weeks before labor begins:

Lightening or dropping: This involves the settling of the baby's head into the pelvis. After lightening, the abdomen will seem lower and will protrude more. It will also be noticeable that the patient can breathe more easily and can eat more at one time.

More Frequent Urination: Lightening may increase the pressure on the pelvis and that, in turn, may lead to awkwardness in walking and the urge to urinate. This could happen as soon as two to four weeks before labor in the first pregnancy, and not until labor begins in the second or third pregnancy.

Backache: The lower position of the baby as well as the baby's larger size, can lead to backache. The patient might have a tough time finding a comfortable sleeping position and make need to use extra pillows as well as all of the relaxation techniques.

Anxiety and Depression: The patient may feel sad and anxious as the due date draws closer or if the due date passes without labor beginning. Try to keep the patient occupied and active with things she enjoys.

Weight and Energy Changes: The patient may find that she loses weight or has a leveling off of weight a few days before the labor starts. About 24 or 48 hours before delivery, the patient may also experience a power surge during which she feels the urge to wash floors, do laundry, and generally clean. Don't let her. She'll need all of her energy for labor.

Bowel Changes: The patient may have more frequent bowel movements within 48 hours of labor. The purpose is to cleanse the lower bowel and prepare the body for birth.

Increased Contractions: The patient may experience contractions as early as the fourth month of pregnancy and even more as the patient prepares for labor. These practice contractions help bring oxygen to her baby's blood and prepare the uterus for labor.

Stages of Labor

First Stage

During the first stage of labor, the contractions of the uterine muscles will cause the cervix to efface and dilate. Effacement is basically the shortening or thinning of the cervix. Dilation, in contrast, refers to the opening of the cervix, which is usually expressed in centimeters--from zero to 10 centimeters, or the point at which dilation is completed. Another term used to indicate progress in labor is station or the location of the baby's "presenting part" -- usually the head -- in relation to certain bones in the pelvis. This indicates how much the baby has advanced or moved through the pelvis and is usually expressed in centimeters above (minus) and below (plus) the level of a certain point on the pelvis.

The healer should do a physical examination to determine effacement, dilatation of the cervix, and the baby's station. While this exam might be a little uncomfortable, it will help the patient and her labor partner understand how far she's progressed.

The first stage of labor is divided into three categories: early, active, and transition.

Early Labor

Early labor is the easiest but longest part of the labor, lasting from two to nine hours. Along with effacement, the cervix is dilating from zero to four centimeters. The contractions are from 30 to 60 seconds long, starting 20 to 30 minute apart and gradually getting closer until they're just five minutes apart. Starting out slow and slightly uncomfortable, the contractions will get stronger as labor progresses. During the rest period between contractions, the patient should feel good, be talkative, and be able to walk around and continue normal activity. At this stage, most women feel confident that they can handle the labor. Others feel fearful that once labor has started, it won't stop.

When her labor starts, it's probably helpful for the patient to get some rest, so that she can do a better job of handling the later phases. The patient should know that as her contractions grow stronger, she'll wake up. That's when she should walk and move around to encourage labor.

During early labor, the patient may want to take in some clear liquids such as tea, juice, or broth. She should also try eating some light, nutritious snacks such as crackers, fruit and toast. During active labor her digestion will slow as much as her desire for food. Moreover, eating during active labor might result in vomiting and aspirating the contents of her stomach into her lungs.

For her labor partner, this is a time to get acquainted with her contractions. If he places his hands on her abdomen, he'll feel that her uterus has become very hard. Sometimes he'll feel a contraction beginning even before she is aware of it and can help the patient prepare for it. He can help the patient time the contractions and make sure she's relaxing with them. If he notices the patient tensing or expressing discomfort during the contractions, he can encourage the patient to relax, change position or urinate. (It's possible that a full bladder could be causing at least some of the discomfort.) If these ideas don't work, the patient might begin some slow-paced breathing.

Active Labor

During active labor, the patient's cervix dilates from four to eight centimeters. After five centimeters, her labor may move forward very quickly. Contractions get stronger (from 45 to 60 seconds), peak sooner, and are typically two to four minutes apart.. If her membranes rupture, it's usually with a gush. She may notice that her contractions become more intense as soon as her water breaks. During this phase she'll probably notice that her mood becomes more and more serious and birth oriented. The patient may want to focus and may begin to doubt her ability to handle the contractions. She'll probably no longer want to chat or play games and may need help staying relaxed.

For her labor partner, this is a time to give reassurance and encouragement. Her partner should keep the healer informed of the patient's progress, help the patient maintain control during the contractions, and help the patient with breathing. The patient will want to hear short commands and suggestions since she probably won't be interested in long conversations.

If the patient's mouth is dry, her partner can get the patient ice chips, or a wet cloth for her to suck on. Or, the patient may want to have a cool cloth applied to her face. If the patient decides to walk around, the patient may want to depend on her partner to stop and support the patient during a contraction. If she's in bed, she'll want to change positions often -- every 20-30 minutes -- and adjust the bed to a comfortable position.

Transition

The transition from the first stage of labor to the second stage is the shortest phase, but it's also the most intense. The cervix is dilating from eight to 10 centimeters with contractions usually 60 to 90 seconds long. These contractions, which peak suddenly and peak more than once, can be as close as one and one-half to two minutes apart. Even though this stage of labor involves short rest periods, the patient may feel as if the contractions are right on top of each other. This can last from 10 minutes to one and one half hours. Transition is a sign that her labor is almost over and the baby is about to enter the world.

Ask her labor partner to be prepared to look for the following signs of transitions. However, be aware that the patient may not experience all of these signs:

• An urge to push or bear down that could be mistaken for a bowel movement
• Belching and hiccups
• Nausea and vomiting
• Shaking or trembling of the legs and body
• Chills or extreme warmth and throwing off the covers
• Cramps in the legs
• Extreme sensitivity to touch
• Spontaneous rupture of membranes, usually with a rush
• Disorientated feelings
• Forgetfulness between contractions
• Sleeping between contractions
• Body mucus discharge
• Confusion or inability to understand directions
• Lack of confidence in her ability to handle labor
• Hopeless feelings
• Panic
• Irritability and restlessness
• Flushed face

During the transition, it's important for her partner to offer encouragement. During this phase, he should take care not to leave the patient alone for any reason. The patient may panic even if she's left alone for a short period of time. Because of her heavy involvement in labor, the patient may want her labor partner to do most of the communicating with the healers. Make sure he knows her needs.

Make sure her labor partner catches each contraction. If she's sleeping or forgets between contractions, the partner should make sure that the patient starts breathing on time. He should help the patient relax between contractions. Remind the labor partner to be patient. Even if the patient yells at him, tell him not to argue or reprimand the patient and to use short and precise commands. If the patient gets confused, ask him to help the patient sit up in bed. If the patient seems to want to give up, have him remind the patient that this is the shortest phase and that labor is almost over.

Her partner needs to be especially careful about responding to the patient if the patient panics. For example, the patient may rock her head from side to side, grip the sheet, his hand or the bed. Or the patient may stop her breathing patterns and instead moan, cry out or even thrash around the bed. In cases like these, the labor partner needs to stand up, grasp her face in his hands, and bring her face close to his. The patient needs to hear that the transition is almost over and the patient only has a few contractions left.

If her back is uncomfortable, she should let her partner know. He can then use pressure, massage the area, or apply a warm and cool cloth. Or, he can put warm socks on her cold feet. To help with trembling legs, he can lightly massage her inner thighs or firmly grasp her legs. And, of course, he can keep a cool cloth on her forehead.

Here's a list of tips for her partner.

• Give as much attention as you can without being overbearing. The patient will need a shoulder she can lean on for support.
• Stay calm and have confidence. Take a few moments out to relax. If a difficult situation arises, take a few moments out, take a deep breath, make the best decision possible and then move on.
• Provide physical and verbal support. Ask if you can hold your partner's hand to help ease pain and tension. If your partner is beginning to panic, but not breathing or coping effectively, turn her face towards yours. Tell her to open her eyes and look directly at you. Hold her firmly and let her know that you're there to help. Remind her what a great job she's doing. If she gets discouraged, remind her of how far she's come and to try to take one contraction at a time.
• Breathe with your partner. If your partner's breathing pattern isn't working, encourage her to try a different one. If the patient forgets the patterns, don't worry. Just remember to start and finish a contraction with a cleansing breath. Breathe at a comfortable rate.
• Make helpful suggestions, as opposed to giving orders. Talk to your partner in between contractions and be sure to ask her if your ideas have been helpful and if there's anything else you can do for her. She may not be able to concentrate so you may need to repeat yourself to make sure she understands you.

Second Stage

The second stage of labor begins when the cervix reaches complete dilatation and effacement and ends with the birth of the baby. Now, the contractions are more like those experienced during the early stages of labor and last about 60 to 75 seconds, about three to five minutes apart. This second stage of labor may last from 10 minutes to two hours -- usually less if she's carrying two or more babies.

At this stage of labor, her mood will probably improve. The patient feels more sociable and talkative and more positive about what she's already achieved and, of course, the birth of her baby. If she's been blowing to combat a premature urge to push, she'll feel the relief of finally being able to work with the contractions. Many women feel an incredible sense of satisfaction and joy as they work hard to push the baby down the birth canal. As her baby descends the birth canal, the patient may notice increased show or discharge, a burning sensation or leg cramps. Moreover, her face may be red and the patient may have a look of intense concentration as she works with the contraction.

While some women experience some pain or discomfort during pushing, it's usually connected with the position of the baby, a large baby, or a pelvic floor that's unrelaxed. The patient may also feel the strong need to have a bowel movement, mostly because her baby's head is pressing against the bowel. Instead of tensing up, relax her bottom. If the patient relaxes her jaw, she'll discover that her pelvic floor also relaxes.

The patient may also feel pressure or burning as the baby nears the perineum. The patient may notice the baby's head--wrinkled and covered with wet hair-- during a contraction . The head will recede during contractions until the top of the baby's head is visible between contractions. This is known as crowning and signals that the head will soon be out. It will then rotate with the face looking toward her thigh. After the healer delivers the shoulders, the baby slides out followed by a large gush of fluid. Once her baby's shoulders are free, the patient or her partner or the healer can reach down and pull the baby onto her stomach.

During this phase, make sure the partner puts the patient in a comfortable pushing position. If she's holding her breath while pushing, make sure he counts for her. Ask him to check her jaw to make sure it's relaxed.

Pushing Positions

The position the patient chooses for pushing will depend on her personal preferences and, of course, the preferences of the healer. While most future mothers choose among squatting, semi-reclining, side-lying, or kneeling on their hands and knees, many healers prefer the semi-reclining position. The healer should discuss all the positions with the patient and have her practice pushing in each position so she will have a sense of what might feel more comfortable during labor. Among her options:

Squatting is probably the best position to use while pushing. If the patient keeps her feet flat on the floor, she can support herself in a squat by holding onto the handrail or her partner. Ask her partner to sit on a chair. Have her squat between his legs, placing her arms over his thighs. Because some women aren't comfortable in the squat position, the patient may want to use the modified squat position. If the patient uses this position, her uterus will get a boost from gravity and make her contractions more efficient, frequent, and longer. To practice this position, her partner should sit or kneel behind the patient and offer back support. The patient can get more comfortable by placing pillows between her partner's legs and her back.

Side-Lying Position: This is a very comfortable position for most women who might have back labor or leg cramps. If her baby isn't already in a face down position, it can also help in rotating the baby. However, there are drawbacks. The patient won't benefit from the force of gravity and her view of the birth might not be as good.

Kneeling: This position is preferred by some women because it takes advantage of gravity, helps when the baby is slow coming down the birth canal, and alleviates back labor. When the patient pushes, tilt her head so that it actually feels as if she's looking for the baby. Then, have her do the following:

• Kneel on the bed facing her partner.
• Put her arms around her partner's shoulders.
• Push or lean up against the raised head of the birthing bed for support.

As an alternative the patient may want to try getting on her hands and knees. If the patient uses this position, the patient can arch her back or rock back and forth doing a pelvic rock. Women whose babies are in a posterior position, where the baby's head is against the mother's spine, often like this position.

Third Stage

The shortest stage of labor lasts no more than five to 20 minutes. Following the birth of the baby, the uterus will begin to contract -- although certainly not as intensely as during labor contractions. The healer may ask the patient to push out the placenta or use pressure to deliver it. Once the placenta is delivered, the healer will examine it to see if it's intact. In some cases, the healer may do an internal exam of the uterus to see that it hasn't retained any placenta.