Preparing for labor

Labor is also called childbirth, labor is the process of your baby leaving the uterus (womb). You’re in labor when you have regular contractions that cause your cervix to change. Contractions are when the muscles of your uterus get tight and then relax. Contractions help push your baby out of your uterus. Your cervix is the opening to the uterus that sits at the top of the vagina. When labor starts, your cervix dilates (opens up).

Stages of labor include the whole process of labor, from your first contractions (stage 1) to pushing (stage 2) to delivery of the placenta (stage 3) after your baby is born. Learning about the stages of labor can help you know what to expect during labor and birth.

Labor is divided into three stages:

1. Labor (stage 1)
2. Pushing and birth (stage 2)
3. Delivery of the placenta (stage 3) 

In most pregnancies, labor starts naturally between 37 and 42 weeks. When labor starts, a number of changes occur in your body:

• your cervix (opening of your uterus / womb) will ‘ripen’ and become soft and open
• you will experience strong, regular contractions that dilate (open) your cervix leading to the birth of your baby
• the bag of membranes (‘waters’) around your baby may break

When labor starts on its own, it is called spontaneous labor.

A labor that is started with medical treatment is called ‘induced’ labor. Induction of labor is a common procedure used to start the process of labor and childbirth. An induction of labor may be recommended when you or your baby will benefit from birth being brought on sooner rather than waiting for labor to start naturally.

The most common reasons for induction are:

• you have a specific health concern, such as high blood pressure
• your baby is overdue (more than 41 weeks)
• there are concerns with your baby (less movements, low fluid, not growing well) your waters have already broken but your contractions have not started naturally.

Every woman’s labor is different. And your labor may be different each time you have a baby. But there are patterns to labor that are true for most women. Learning about the stages of labor and what happens during each one can help you know what to expect once labor begins.

Lots of pregnant women take childbirth classes to learn what happens during labor and birth. These classes can help you feel ready when labor starts so you’re not scared or surprised. You’ll learn how to breathe and relax to help with labor pain. And you’ll learn about different ways your health care provider can reduce your pain during labor.

You can probably take a childbirth class at your hospital. Some classes are free or low cost. Ask your provider if you need help finding a class. Think about taking a class in your sixth or seventh month of pregnancy. And take your partner or a friend with you who will be there to help during labor.

What happens in the first stage of labor?

The first stage of labor is the longest stage. For first-time moms, it can last from 12 to 19 hours . It may be shorter (about 14 hours) for moms who’ve already had children. It’s when contractions become strong and regular enough to cause your cervix to dilate (open) and thin out (efface). This lets your baby move lower into your pelvis and into your birth canal (vagina). This stage of labor ends when you are 10 centimeters dilated. The first stage is divided into three parts: early labor, active labor and transition to stage 2 of labor.

Early labor

For most first-time moms, early labor lasts about 6 to 12 hours. You can spend this time at home or wherever you’re most comfortable. During early labor:

You may feel mild contractions that come every 5 to 15 minutes and last 60 to 90 seconds.
You may have a bloody show. This is a pink, red or bloody vaginal discharge. If you have heavy bleeding or bleeding like your period, call your provider right away.

What you can do in early labor:

This is a great time for you to rely on your doula or labor support person. A doula is a trained professional who provides information and physical and emotional care and support to women before, during and after childbirth, including continuous support through labor and birth. Try the methods you learned about in childbirth education classes about how to relax and cope with pain.

During early labor:

• Rest and relax as much as you can.
• Take a shower or bath.
• Go for a walk.
• Change positions often.
• Make sure you’re ready to go to the hospital.
• Take slow, relaxing breaths during contractions.

Active labor

This is when you head to the hospital! Active labor usually lasts about 4 to 8 hours. It starts when your contractions are regular and your cervix has dilated to 6 centimeters. In active labor:

• Your contractions get stronger, longer and more painful. Each lasts about 45 seconds and they can be as close as 3 minutes apart.
• You may feel pressure in your lower back, and your legs may cramp.
• You may feel the urge to push.
• Your cervix will dilate up to 10 centimeters.
• If your water hasn’t broken, it may break now.
• You may feel sick to your stomach.

What you can do in active labor:

• Make sure the hospital staff has a copy of your birth plan.
• Try to stay relaxed and not think too hard about the next contraction.
• Move around or change positions. Walk the hallways in the hospital.
• Drink water or other liquids. But don’t eat solid foods.
• If you’re going to take medicine to help relieve labor pain, you can start taking it now. Your choice about pain relief is part of your birth plan.
• Go to the bathroom often to empty your bladder. An empty bladder gives more room for your baby’s head to move down.
• If you feel like you want to push, tell your provider. You don’t want to start pushing until your provider checks your cervix to see how dilated it is.

Transition to the second stage of labor

This can be the toughest and most painful part of labor. It can last 15 minutes to an hour. During the transition:

• Contractions come closer together and can last 60 to 90 seconds. You may feel like you want to bear down.
• You may feel a lot of pressure in your lower back and rectum. If you feel like you want to push, tell your provider.

What happens in the second stage of labor?

In the second stage of labor, your cervix is fully dilated and ready for childbirth. This stage is the most work for you because your provider wants you to start pushing your baby out. This stage can be as short as 20 minutes or as long as a few hours. It may be longer for first-time moms or if you’ve had an epidural. And epidural is pain medicine you get through a tube in your lower back that helps numb your lower body during labor. It’s the most common kind of pain relief used during labor. The second stage ends when your baby is born.

During the second stage of labor:

• Your contractions may slow down to come every 2 to 5 minutes apart. They last about 60 to 90 seconds.
• You may get an episiotomy. This is a small cut made at the opening of the vagina to help let the baby out. Most women don’t need an episiotomy.
• Your baby’s head begins to show. This is called crowning.
• Your healthcare provider guides your baby out of the birth canal. She may use special tools, like forceps or suction, to help your baby out.
• Your baby is born, and the umbilical cord is cut. Instructions about who’s cutting the umbilical cord are in your birth plan. What you can do:
• Find a position that is comfortable for you. You can squat, sit, kneel or lie back.
• Push during contractions and rest between them. Push when you feel the urge or when your provider tells you.
• If you’re uncomfortable or pushing has stopped, try a new position.

What happens in the third stage of labor?

In the third stage of labor, the placenta is delivered. The placenta grows in your uterus and supplies your baby with food and oxygen through the umbilical cord. This stage is the shortest and usually doesn’t take more than 20 minutes.

During the third stage of labor:

• You have contractions that are closer together and not as painful as earlier. These contractions help the placenta separate from the uterus and move into the birth canal. They begin 5 to 30 minutes after birth.
• You continue to have contractions even after the placenta is delivered. You may get medicine to help with contractions and to prevent heavy bleeding.
• Your healthcare provider squeezes and presses on your belly to make sure the uterus feels right.
• If you had an episiotomy, your provider repairs it now.
• If you’re storing your umbilical cord blood, your provider collects it now. Umbilical cord blood is blood left in the umbilical cord and placenta after your baby is born and the cord is cut. Some moms and families want to store or donate umbilical cord blood so it can be used later to treat certain diseases, like cancer. Your instructions about umbilical cord blood can be part of your birth plan.
• You may have chills or feel shaky. Tell your provider if these are making you uncomfortable.

What you can do:

• Enjoy the first few moments with your baby.
• Start breastfeeding. Most women can start breastfeeding within 1 hour of their baby’s birth.
• Give yourself a big pat on the back for all your hard work. You’ve made it through childbirth.

How do I know when I’m in labor?

• You have strong and regular contractions. A contraction is when the muscles of your uterus tighten up like a fist and then relax. Contractions help push your baby out.
• Your contractions come about 5 to 10 minutes apart.
• Your contractions are so strong you can’t walk or talk during them.
• Your water breaks. Your baby has been growing in amniotic fluid (bag of waters) in your uterus. When the bag of waters breaks, you may feel a big rush of water. Or you may feel just a trickle.
• You have a bloody (brownish or reddish) mucus discharge. This is called bloody show.
• You feel pain in your belly and lower back. This pain doesn’t go away when you move or change positions.

What is preterm labor?

Preterm labor is labor that begins too early, before 37 weeks of pregnancy. Premature babies (born before 37 weeks of pregnancy) can have health problems at birth and later in life. If you’re not to 37 weeks of pregnancy and you have signs or symptoms of preterm labor, call your provider. Getting help quickly is the best thing you can do. Learn about risk factors for preterm labor and what you can do to help reduce your risk.

What are the different ways you can have your baby?

• Vaginal birth. This is the way most babies are born. During vaginal birth, your uterus contracts to help push the baby out through your vagina.
• Cesarean birth. Also called a C-section. A cesarean section is surgery in which your baby is born through a cut that your doctor makes in your belly and uterus. If there are problems with your pregnancy or your baby’s health, a c-section may be safer than vaginal birth. You and your provider may plan for a c-section. Or you may need to have an emergency (unplanned) c-section if something goes wrong during pregnancy, labor or birth. If your pregnancy is healthy and you don’t have any medical reasons to have a c-section, it’s best to have your baby through vaginal birth.
• Vaginal birth after cesarean also called VBAC. If you’ve already had a cesarean birth, you may be able to have a vaginal birth in your next pregnancy. Talk to your provider to see if VBAC is safe for you.

Scheduling your baby’s birth means you and your health care provider decide when to have your baby instead of waiting for labor to begin on its own. Scheduling birth a little early for non-medical reasons can cause problems for you and your baby. If your pregnancy is healthy, it’s best to stay pregnant for at least 39 weeks. This gives important organs — like your baby’s brain, lungs, liver, eyes and ears — time to develop before birth.

If your pregnancy is healthy, wait for labor to begin on its own. If you choose to induce labor, talk to your provider about waiting until you’re full term at 39 weeks. Inducing labor or having a c-section before 39 weeks should only be for medical reasons. Inducing labor means your provider gives you medicine or breaks your water to make your labor begin.

What happens after my baby is born?

Right after birth your provider places your baby skin-to-skin on your chest and covers him with a blanket. Holding your baby skin-to-skin helps your baby stay warm as he gets used to being outside the womb. It’s also a great way to get started breastfeeding. You can start breastfeeding even within an hour of your baby’s birth. Even if you don’t plan to breastfeed, hold your baby skin-to-skin so you get to know each other right away. Your baby will welcome your gentle touch, and this closeness can help you and your baby bond.

After birth, your body starts to change to help you heal. Your healthcare provider takes your temperature and checks your heart and blood pressure to make sure you’re doing well. If you had anesthesia during labor, your healthcare provider makes sure you’re recovering without any complications.

What is a birth plan?

A birth plan is a set of instructions you make about your baby’s birth. A birth plan includes things like:

• Where you want to have your baby
• Who you want to be with you during labor and birth
• What position you’d like to give birth in
• If you want medicine to help with labor pain
• If there are cultural traditions you’d like to follow during labor and birth
• If you plan to breastfeed

A birth plan tells your doctor how you feel about things like who you want with you during labor, what you want to do during labor, if you want drugs to help with labor pain, and if there are special religious or cultural practices you want to have happen once your baby is born.

It’s a good way to let your midwife or doctor know what kind of care you’d like in labor, birth and afterwards (if possible), and if you’re planning to breastfeed.

A birth plan will also help you be more involved in decisions about your care and help you prepare for the big event. But before you make a plan, you need to know more about what birth is like and what choices you have.

You can find out more by:

• going to your antenatal classes
• asking your midwife or doctor about any issues or concerns you have about the approaching labor and birth
• ask about who will be involved in your care, how many people will be involved and who has access to your medical records
• reading about birth
• talking to other mothers who have given birth at the hospital or birth center you are going to, or to women who have had a homebirth, if that is what you are planning
• talking to your partner or other relatives or friends who’ll be there to support you at the birth. What sort of labor and birth would they like you to have? How do they see their role?

Remember that things may not go according to plan. There may be complications or you may change your mind about something. Some women say they want to give birth without pain-relieving drugs, for instance, then find they need them after all — and that’s OK.

So think of the birth plan as a guide, and stay flexible.

Things to think about:

• Where do I want to have my baby?
• Who do I want with me in labor (birth companion), for example my partner, my children, another family member or a friend? Support in labor is important.
• Do I want my birth companion to stay with me all the time, or are there certain procedures or stages in labor when I would prefer them to leave the room?
• How would I like the birth environment to be: do I want music, and low lighting?
• What birthing aids am I likely to need in labor — for example a beanbag, squatting bar or birth stool?
• Do I want pain relief — if so, what kind? Are there any types of pain relief I want to avoid?
• How will the type of pain relief I choose affect the labor or the baby?
• What position do I want to try during labor and to give birth in?
• What is the usual practice for an episiotomy?
• If my labor slows down or is taking too long, do I want my caregiver to do anything to speed it up? Or would I prefer to wait?
• What if I need a caesarean? Would I prefer to have a caesarean with an epidural anaesthetic so I can stay awake? Do I want my partner to be with me — and will my partner be able to cope?
• What is the usual practice for an induction?
• What procedures may be recommended and why?
• What equipment may be used in my pregnancy care, and for the birth of my baby, and why?
• Who will cut the cord?
• Do I want to have an injection to speed up the delivery of the placenta or not?
• Do I have any cultural or religious needs around giving birth?

When you decide about any kind of treatment it’s important to make decisions based on good information. Talk to your midwife or doctor about the pros and cons of different treatments before you’re likely to need them. Think of your own safety and wellbeing and that of your baby when you make these decisions. It is a good idea to have gone through your birth plan with your caregivers before you are 36 weeks pregnant.

Figure 1. Birth plan

How to use your birth plan

Fill out a birth plan with your partner. Then share it with your provider and with the nurses at the hospital or birthing center where you plan to have your baby. Share it with your family and other support people, too. It’s best for everyone to know ahead of time how you want labor and birth to be.

Signs your body is preparing for labor

Signs that you may be close to starting labor

You may be close to starting labor if:

• Your baby drops or moves lower into your pelvis. This is called lightening. It means that your baby is getting ready to move into position for birth. It can happen a few weeks or even just a few hours before your labor begins.
• You have an increase in vaginal discharge that’s clear, pink or slightly bloody. This is called show or bloody show. It can happen a few days before labor starts or at the beginning of labor.
• At a prenatal checkup, your health care provider tells you that your cervix has begun to efface (thin) and dilate (open). Before labor, your cervix is about 3.5 to 4 centimeters long. When it’s fully dilated (open) for labor, it’s 10 centimeters. Once labor starts, contractions help open your cervix.
• You have the nesting instinct. This is when you want to get things organized in your home to get ready for your baby. You may want to do things like cook meals or get the baby’s clothes and room ready. Doing these things is fine as long as you’re careful not to overdo it. You need your energy for labor and birth.

If you have any of these signs, you may start labor soon. Learn the signs of labor so you know when to call your provider.

You’ll know you’re in true labor when:

• You have strong and regular contractions. A contraction is when the muscles of your uterus tighten up like a fist and then relax. Contractions help push your baby out. When you’re in true labor, your contractions last about 30 to 70 seconds and come about 5 to 10 minutes apart. They’re so strong that you can’t walk or talk during them. They get stronger and closer together over time.
• You feel pain in your belly and lower back. This pain doesn’t go away when you move or change positions.
• You have a bloody (brownish or reddish) mucus discharge. This is called bloody show.
• Your water breaks. Your baby has been growing in amniotic fluid (the bag of waters) in your uterus. When the bag of waters breaks, you may feel a big rush of water. Or you may feel just a trickle.

​If you think you’re in labor, call your health care provider, no matter what time of day or night. Your provider can tell you if it’s time to head for the hospital. To see for sure that you’re in labor, your health care provider measures your cervix.

What are false labor and Braxton-Hicks contractions?

Not all contractions mean you’re in labor. You may have contractions on and off before true labor starts. These contractions are called false labor or Braxton-Hicks contractions. They soften and thin the cervix to help your body get ready for labor and birth. You may feel them in the weeks right before your due date. Learning the differences between true labor contractions and false labor contractions can help you know when you’re really in labor.

It can be hard to tell the difference between true labor and false labor. When you first feel contractions, time them. Write down how much time it takes from the start of one contraction to the start of the next. Make a note of how strong the contractions feel. Keep a record of your contractions for 1 hour. Walk or move around to see if the contractions stop when you change positions.

Preparing for induction at 39 weeks

In most pregnancies, labor starts naturally between 37 and 42 weeks. If your pregnancy is healthy, wait for labor to begin on its own. Babies aren’t fully developed until at least 39 weeks.

When labor starts, a number of changes occur in your body:

• your cervix (opening of your uterus / womb) will ‘ripen’ and become soft and open
• you will experience strong, regular contractions that dilate (open) your cervix leading to the birth of your baby
• the bag of membranes (‘waters’) around your baby may break

When labor starts on its own, it is called spontaneous labor.

A labor that is started with medical treatment is called ‘induced’ labor. You may have heard it referred to simply as induction or getting induced. Induction of labor is a common procedure used to start the process of labor and childbirth. Induction of labor is a way of artificially starting the process of childbirth, for babies who are physically ready to enter the world, but aren’t interested in leaving the cozy cocoon of mum’s womb. An induction of labor may be recommended when you or your baby will benefit from birth being brought on sooner rather than waiting for labor to start naturally.

The most common reasons for induction are:

• you have a specific health concern, such as high blood pressure
• your baby is overdue (more than 41 weeks)
• there are concerns with your baby (less movements, low fluid, not growing well) your waters have already broken but your contractions have not started naturally.

But induction of labor does involve some risks for mother and baby, so will only be performed when the benefit of the procedure outweighs the risks.

More than one in four pregnant women end up getting induced because:

• Their baby is overdue but needs a little bit of coaxing out into the world;
• They have a medical condition (most commonly diabetes) or pregnancy complication (most commonly premature rupture of the membranes) which creates health risks if they continue the pregnancy; or
• There is something wrong with the baby for example it is not growing properly, and may be in danger if the pregnancy continues.

However even in these situations, your doctor may not induce labor. If, after having the risks and benefits of induction of labor explained, the pregnant woman does not agree to be induced the procedure will not be performed.

When is induction of labor dangerous?

There are also some situations when labor will not be induced because it is too dangerous (no matter how much mum is ready and willing to do just about anything to get baby out of there). These are usually situations in which a vaginal birth is not possible, and a cesarean section (C-section) is the recommended method of bringing baby into the world.

Labor will not be induced unless the baby is doing everything just right. For example, if baby is not in the right position for vaginal birth (malpresentation) or the position of the umbilical cord poses a danger during vaginal birth, induction of labor is contraindicated meaning it’s a big no-no in doctor speak.

Similarly if the placenta or umbilical vessels are covering mum’s cervix, (conditions referred to as placenta previa and vasa previa respectively) getting induced is out of the question. If baby experiences sudden changes that indicate it may be distressed, for example if its heart rate slows down or it is not getting enough oxygen, induction is too dangerous.

Mums also needs to be just right to undergo induction of labor and vaginal delivery of their baby. Doctors won’t induce women with cephalopelvic disproportion (which means there’s not enough room for baby’s head to pass through their pelvic bone). For those with viruses (like HIV and genital herpes) that may infect their baby during normal medical procedures carried out for induction of a vaginal delivery such as breaking the waters, induction of labor also poses too great a risk.

What type of induction am I likely to have?

There are different ways to induce labor. To determine the best method of induction for you, your doctor or midwife will do a vaginal examination to check how ready your cervix is.

Based on this examination, they will recommend one of the following methods of induction:

• a hormone called prostaglandin
• balloon catheter
• artificial rupture of membranes (ARM)
• a hormone called syntocinon

The process of induction will vary for everyone. It may require one or a combination of these methods.

Ripening the cervix for induction of labor

Mum’s cervix also needs to be just right, or to use the correct medical term, the cervix must be ripe. The cervix is the entrance to the womb and it’s usually closed off to prevent all but the tiniest of particles (think sperm) entering the womb. However before the baby can move from the uterus through to the vagina to be born, the cervix needs to open up, or dilate to make room for baby’s head to pass through. The ripeness of the cervix is assessed by calculating the Bishop’s score.

As the cervical canal becomes wider it shortens and softens in preparation for baby’s passage. If all’s going well and baby’s in the correct position, this means the cervix is ready for childbirth, and labor can be induced.

If the cervix is not ripe, induction of labor is not out of the question. But the cervix must be ripened, by applying a gel or pessary containing chemicals called prostaglandins which help the cervix dilate, or by transcervical foley catheter, a procedure in which a catheter is inserted into the cervix to encourage it to soften and dilate. That usually takes at least six hours with prostaglandin gel and 12-18 hours with a transcervical foley catheter.

Methods of induction​

Once the cervix is just right (ripe) and the woman’s bladder empty, induction of labor can begin. There are two techniques; artificial rupture of the membranes and administration of the hormone oxytocin, which may also be used in combination.

Artificial rupture of the membranes is a procedure in which a small cut is made to the pregnancy membranes, the amnion and chorion, causing them to rupture. When labor occurs spontaneously, these membranes rupture without intervention, in a pregnancy event often referred to as the ‘waters breaking’. Once the membranes are ruptured doctors may wait for labor to start spontaneously, induce labor with oxytocin or use augmentation of labor techniques.

Oxytocin is a hormone produced naturally by the human body which stimulates contractions of the uterus (those same contractions which help move baby out into the world during childbirth). So administering a bit of extra oxytocin is an effective way of stimulating labor contractions. If this hormone is administered, the woman will be attached to a monitor which track her uterine contractions and her baby’s heart rate.

Prostaglandins

Prostaglandin is a naturally occurring hormone that prepares your body for labor. A synthetic version has been developed to mimic your body’s natural hormone. This hormone is placed in your vagina either as a gel or pessary (like a tampon) that works to ripen your cervix. Once the prostaglandin has been inserted, your baby will be monitored and you will need to stay in hospital.

Occasionally you may need more than one dose of prostaglandin. When the prostaglandin takes effect, your cervix will be soft and open and the next steps of your induction can start.
Some women may have their membranes ruptured (‘waters broken’) but this may happen naturally. Some women may require syntocinon to stimulate contractions.

Balloon catheter

Prostaglandins are not suitable for all women, for example, if you have had a previous caesarean section or a reaction to prostaglandins in the past. Your doctor may therefore recommend a balloon catheter to ripen your cervix.

This catheter is a thin tube which is placed inside your cervix and a small balloon inflated to place pressure on your cervix. This pressure should soften and open your cervix. This catheter will stay in place for several hours until either it falls out (indicating your cervix has opened) or until you are re-examined.

Artificial rupture of membranes (‘breaking your waters’)

If your waters have not broken, artificial rupture of membranes may be recommended. This is when your doctor or midwife puts a small hole in the bag of membranes or waters around your baby. This is done with a small instrument during a vaginal examination and can only occur once your cervix is open. Once your membranes have ruptured, contractions may start naturally, if not, a syntocinon infusion will be started.

Syntocinon

Syntocinon is a synthetic hormone that mimics your body’s natural hormone called Oxytocin. It is given through an intravenous infusion (drip) in your arm and stimulates contractions of the uterus. The infusion is slowly increased until you are having strong regular contractions. The infusion will continue until after your baby is born.

Once syntocinon has started, your baby’s heart rate will be monitored throughout labor using a cardiotocography (CTG) or electronic fetal monitoring (EFM) machine. Cardiotocography (CTG) is a technical means of recording the fetal heartbeat and the uterine contractions during pregnancy.

Childbirth after induction

Sometimes there are complications, for example uterine contractions fail to start or gain sufficient momentum for labor, uterine contractions occur too quickly or the baby’s heart rate changes. In these cases the hormones used to induce labor may be withdrawn, and sometimes an emergency cesarean section needed.

However, most women go on to deliver their baby vaginally after induction of labor. It is a common procedure performed in more than one in four pregnancies. As the procedure will only be performed when the benefits for both mum and bub outweigh the risks, you can rest assured that there’s a good reason, if your doctor asks you to consider induction of labor.

What risks are involved with an induction of labor?

• The induction may not work. Occasionally, the process to ripen the cervix does not work, which means your cervix has not opened enough for the membranes to be ruptured. If this happens, your doctor will talk to you about your options. These may include, returning home until a later date, using a different method of induction, or you may require a caesarean section. Sometimes, after your membranes have ruptured, contractions may not start and labor does not establish. In this situation, your doctor will recommend a caesarean section.
• Over-stimulation of the uterus. One of the side effects of the synthetic hormones is they may cause the uterus to contract too much. This can sometimes cause stress to you and your baby. If this occurs, you may be given medicine to relax the uterus. If you have a hormone pessary, it will be removed.
• Induction can be more painful than natural labor.
• Increased intervention. There may be an increased risk of further intervention in labor such as instrumental delivery (with forceps or ventouse) or caesarean section in some cases. However, it is always important to balance the risks and benefits of induction of labor carefully and discuss with your doctor or midwife.