During the first stage of labour, your body goes through some changes in preparation. It's not always easy to tell exactly when labour has started.
When your baby is ready to be born, the balance of hormones in your body changes. This makes your cervix (the neck of your womb) become softer and shorter.
You may also have what is called a show. This is when the plug of mucus that acts as a seal in your cervix during pregnancy falls out as your cervix changes shape. This may happen any time between several days and a few hours before labour starts.
Hormones also cause contractions. The muscles in your womb tense and relax so that your cervix stretches and opens (dilates). Contractions feel like a wave. They start gently and gradually build becoming intense and then easing off. It may take some time for your contractions to become regular but they gradually get stronger and closer together.
The first stage of labour is often defined in two periods – the latent first stage and the established first stage. During the latent first stage, you will have irregular contractions, which may be uncomfortable, and your cervix will dilate by up to 4cm. For some women, contractions are not particularly painful at this stage. The latent phase of labour can last for several hours. In the established first stage, you will have more regular, painful contractions and your cervix will continue to dilate from 4cm up to 10cm.
At first you may only have a contraction every 10 to 30 minutes. After a while, they will be more frequent and stronger, occurring every three to five minutes. The length of time that each contraction lasts is usually between 10 and 40 seconds to begin with. They get longer as your labour progresses, to around 45 to 60 seconds. But this will be different for every woman.
Contractions feel different to each woman. Sometimes they feel like period cramps. Sometimes your bump feels very tight with a lot of pressure in the lower part of your abdomen. Some women feel discomfort in their lower back. You may also find that your waters break. This is a normal part of labour and is when the bag of fluid that surrounds your baby breaks as your cervix widens. The fluid may rush out in one go or in a steady leak. Your waters can break at any time during labour. If your waters break when you're not in labour and labour doesn't start within a few hours, contact your midwife or doctor for advice about what to do next. Normally the water is clear, however if there’s any bleeding or the water is green, you must get advice from your doctor or midwife immediately.
At 10cm, your cervix is fully dilated, allowing your baby to move lower through your pelvis. For women having their first baby, labour usually lasts for about eight hours, most of which is the first stage of labour. Labour is unlikely to last longer than 18 hours. It's likely to take less time if it's not your first baby because your pelvis and vagina have been stretched before.
The second stage of labour is when you give birth to your baby. It usually lasts for about one or two hours.
As your baby's head gets lower, you will eventually feel a strong urge to push. This helps your baby to be born. It’s a unique feeling which your body does of its own accord. You will have contractions which help you push. They may be less frequent but last longer. You may also feel more comfortable if you are upright, kneeling, sitting or squatting.
As you push, your baby moves further down through your pelvis until the head stays at the entrance to your vagina between contractions. This is called 'crowning' and means your baby is about to be born. Usually, your baby’s head is born first, followed by the shoulders and the rest of the body. Your midwife will guide you when to push when your baby’s head is crowning. They will also frequently ask you to pant so that the head is born more slowly. This makes you less likely to tear.
During the third stage of labour, the placenta and membranes that held your baby in the womb are passed out of your body. You can let this happen naturally or you can have a medicine to help the process.
Active management of the third stage by your midwife or doctor
Your midwife or doctor can help the third stage to progress more quickly and safely. As your baby's shoulders and head are being born, you will be given an injection of a hormone called oxytocin. Or a combination of oxytocin and a medicine called ergometrine. After a few minutes, these cause your womb to contract strongly to help reduce serious bleeding. The umbilical cord is clamped and cut up to three minutes after your baby is born. Your midwife or doctor will then deliver the placenta by pulling gently with one hand on the part of the umbilical cord that is still attached to it.
This normally takes around five minutes but can take up to 30 minutes. Research has shown that this method reduces your risk of serious bleeding. However, it's possible that you will have some side-effects as a result of the medicines. These can include headache and feeling sick. Or vomiting, if you were given an injection of ergometrine.
Natural (physiological) management of the third stage
You may choose for the placenta to be delivered without any medicines. After your baby is born, you will be encouraged to cuddle him or her and try breastfeeding. This causes hormones to be released which help your womb to contract and push out the placenta. The umbilical cord isn't clamped and cut until the placenta has been delivered. This can take anything from a few minutes to about an hour.
Natural third stage increases the risk of bleeding after delivery. This risk is higher if you have given birth more than five times before. There are a number of reasons why this natural type third stage may not be possible.
- If you had a general anaesthetic or an epidural in labour, or you’ve had a long labour.
- If you had heavy bleeding during this pregnancy or with a previous birth.
- If there were problems during labour or if you had an assisted delivery.
Your midwife or doctor will give you more information about your options.
Complications are when problems occur during or after a vaginal delivery. Sometimes labour doesn't go as planned and you may need help for your baby to be born safely.
Induction of labour
Induction is when you’re helped to go into labour. Around one in five women will have their labour induced. There are a number of reasons why induction may be suggested.
- If there’s a problem with you or your baby and you need to give birth to your baby early.
- Some birthing units may induce you if your pregnancy is overdue. This can differ between birthing units though.
- If your waters have broken, but labour hasn't started 24 hours later.
There are several methods that can be used to induce labour. Membrane sweeping is when your midwife or doctor puts their finger inside your cervix and makes a circular movement. This separates the membranes around the baby from your womb and releases hormones, which can start your labour. If this doesn't happen, there are a number of other ways that your labour can be started. These are explained below.
- Prostaglandins. This is the way that most women will have their labour induced. Prostaglandins are hormones that are usually produced by your body to trigger the beginning of labour. They stimulate your cervix to get softer and shorter. You will have either tablets or a gel placed into your vagina.
- Rupture of membranes. This is when you artificially have your waters broken. It's done using a special plastic probe. Rupturing your membranes causes hormones to be released that can start your labour.
- Oxytocin. This causes your womb to contract. You will receive it through a drip inserted into your arm. Oxytocin is usually given if your membranes have already ruptured.
Having labour induced can be more painful than going into labour naturally. Talk to your midwife or doctor about pain relief during your labour.
Acceleration of labour
Sometimes, your labour may take a long time and not progress at the rate that would usually be expected. If this happens, you may be offered treatment to speed up the dilation of your cervix and strengthen your contractions. This is also known as augmentation of labour. You may be given oxytocin through a drip to help your womb contract more strongly. If your waters haven't broken, then your midwife or doctor may also suggest having the membranes ruptured to speed up labour.
Sometimes your doctor may need to use instruments to help you give birth to your baby. Some of the main reasons why you may need help are listed below.
- Your baby isn't getting enough oxygen, or there’s another problem putting his or her health at risk. This is called fetal compromise or fetal distress.
- Your baby’s in a position that means it's difficult to be born without help.
- You’ve been pushing for a long time and very tired, and can't manage without assistance.
- You have a health condition that means you may not be able to keep pushing.
You will usually be given local or regional anaesthesia before an assisted delivery. The two types of assisted delivery are listed below.
- Forceps. These are like large tongs with curved ends that fit around your baby's head. Your doctor will pull gently on them while you push.
- Vacuum extraction. This uses suction. A cup is placed on your baby's head and attached to a vacuum machine. The air is sucked out which attaches the cup strongly to the baby's head. Your doctor then pulls gently on the cup as you push.
If you need an assisted birth, your midwife or doctor will give you more information about your options.
If it's not possible for you to give birth to your baby vaginally, you will need an operation called a caesarean delivery. This involves delivering your baby through your abdomen (tummy).
You may plan in advance to have a caesarean delivery, which is called a planned or elective caesarean. Or, you may go into labour and then need an emergency caesarean because of complications that develop. It’s also possible that you may need an emergency caesarean before you go into labour.
All women cope differently with labour. Before you go into labour, you may have an idea about the pain relief you wish to have. This may change once it's actually happening. There’s evidence to show that having someone with you throughout labour can reduce your need for painkillers.
There are a number of methods of pain relief that you can try if you don't want to use medicines. These methods include:
- using breathing and relaxation techniques, or massage
- being in warm water, such as a birthing pool
- moving around, standing up, kneeling and leaning forward
Some women have found that using a TENS (transcutaneous electrical nerve stimulation) machine can also help during early labour. Four electrodes are placed on your back and electrical impulses are sent to the nerves to block pain signals going from your womb to your brain. However, TENS isn't recommended later on in labour.
If you decide to use medicines, all these self-help methods can also be used at the same time.
There are a number of medicines you can choose for pain relief. They can be used in combination if necessary. It's important to talk to your midwife or doctor about these and to be sure that you’re aware of the risks and benefits of each.
Gas and air (Entonox)
This is a mixture of nitrous oxide and oxygen. As you feel a contraction start, you breathe in the mixture through a mouthpiece or a mask placed over your nose. It's a mild painkiller and will make you less aware of your pain. You may find that Entonox makes you feel sick and light-headed.
Opiods are strong painkillers that are injected into a muscle in your leg or arm. These medicines include diamorphine and pethidine. They can cause side-effects, including feeling sick, dizzy or very sleepy. It’s not always recommended to take opioids so speak to your doctor about the pros and cons.
An epidural is an injection of anaesthesia into your lower back, just above your waist. An epidural blocks pain from your waist down. It's very effective and nine out of 10 women who have one have no pain at all. However, there can be side-effects. If you have an epidural, your second stage of labour may take longer because you won't feel the urge to push. It may also make moving around more difficult because you have less feeling in your back and legs. However, some birthing units are able to offer you a mobile epidural. This uses a lower dose of local anaesthetic plus an opioid painkiller. It allows you to walk about and use different positions, which you may prefer.
Can I have a drink or something to eat while I'm in labour?
Yes, although you may not feel like eating anything once you’re in active labour. It's a good idea to keep well hydrated during labour.
You can eat during labour, unless you have had opioid painkillers, such as pethidine or diamorphine. Or if there’s a high chance that you will need to have a general anaesthetic.
Unless you’re advised not to, it’s fine to eat normally in the early stages of labour if you feel like it. This may be helpful because you will use up a lot of energy giving birth to your baby. It may help to have carbohydrates, such as cereal, bread or a banana as these release energy slowly, over a longer period of time.
Drinking water during labour is a good idea, if you feel like it.
Are Braxton Hicks contractions the same as the contractions that I’ll have during labour?
No, Braxton Hicks contractions are different from the contractions you will have when your baby is born.
Braxton Hicks contractions are also sometimes called practice contractions. You may start to get this kind of contraction from around the middle of pregnancy. As your pregnancy progresses, you may feel them more often and they may get stronger.
Braxton Hicks contractions are different from the contractions that occur during labour, which are more powerful and come at regular intervals. Braxton Hicks contractions are irregular and you probably won't find them as painful, although they may be uncomfortable.
Can I give birth at home?
Some women who have a straightforward pregnancy choose to give birth to their baby at home. However, there’s not enough information available to say if having a home birth is as safe as a hospital birth.
During pregnancy, you will need to think about where you want to give birth to your baby. There are several options and one of these includes having a home birth. You may decide that you would prefer to give birth to your baby at home rather than in a hospital. This could be for various reasons. For example, because you will feel more relaxed in familiar surroundings.
Some studies have shown that women who have a planned home birth are less likely to have medical treatments, such as pain relief or to have assisted delivery.
However, there’s not enough information available to say for sure whether it is safer to have your baby at home or in hospital. A study of healthy and normal pregnancies in England in 2011 showed that:
- if it’s your first baby, it’s slightly safer for the baby to give birth in hospital
- if it’s your second or subsequent baby, there’s no difference in safety whether you give birth at home or in hospital
However, a large US study found that babies born at home or in a midwife unit had a higher risk of problems soon after birth.
There may be reasons why it's best for you to give birth to your baby in hospital. These include:
- having a condition such as diabetes or high blood pressure
- if you’re expecting more than one baby
- having had complications during this pregnancy or a previous pregnancy
It's important to remember that you won't be able to have an epidural if you choose to give birth at home. It will also take longer to get emergency care for you or your baby if problems develop during labour.
There are a number of other places where you can choose to give birth, such as birth centres run by midwives. Your midwife or doctor will be able to give you more information about your options. And remember, you can change your mind at any time about where you wish to give birth.
Are there any benefits to using water during labour?
Yes, there’s evidence to show that being in water during labour may reduce your need for pain-relief medicines and make your contractions less painful. It may slightly reduce the need for labour to be speeded up.
You may find water helpful as a method of pain relief. There’s evidence that being immersed in water during the first stage of labour may reduce the pain you feel and the need for an epidural. You may also have a shorter first stage of labour.
You may also want to give birth to your baby while you’re in water. You should speak to your midwife or doctor for more information about giving birth in water. There’s currently a lack of evidence to show whether or not there are any increased risks to you or your baby.
Some hospitals and birth centres have birthing pools. It's also possible to hire birthing pools to use at home.
What will happen if I'm having twins or triplets?
If you’re pregnant with twins, you may be able to give birth vaginally to one or both of your babies. If you’re having triplets, they will be delivered by caesarean.
If you’re pregnant with twins, triplets or even quadruplets, this is called a multiple pregnancy. About 16 pregnant women in every 1000 in the United Kingdom in 2011 had a multiple pregnancy. Women who become pregnant after in vitro fertilisation treatment (IVF) have a higher chance of having twins or more.
If you’re pregnant with triplets or quadruplets, you will be advised to have them delivered by caesarean. If you’re expecting twins, you’re more likely to need a caesarean delivery than if you were pregnant with one baby. However, it's often possible for at least one, if not both, of your twins to be born vaginally. If the first twin is in the head downwards position, then it's likely that vaginal labour and birth can go ahead.
After the first baby is born, you may stop having contractions. If they don't start again, you will probably be given oxytocin to encourage your uterus (womb) to start contracting. Your midwife or doctor will examine you to see which way your second baby is pointing. They may try to turn your baby into a good position to be born vaginally, or you may need to have a caesarean delivery.
Is complementary therapy helpful for pain relief during labour?
Relaxation, acupuncture and massage may be helpful to reduce pain during labour. However, there’s a lack of evidence to show whether other kinds of complementary therapies are effective.
Many women give birth with little use of medicines for pain relief. Massage may help you relax and reduce your anxiety during labour. Acupuncture may also reduce pain in labour. There isn’t enough information to say whether aromatherapy and hypnotherapy reduce pain in labour. It's important to speak to your midwife or doctor before trying any complementary therapy. If you do decide to use a complementary therapy, make sure that you only go to a registered practitioner.
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- Intrapartum care: care of healthy women and their babies during childbirth. National Institute for Health and Clinical Excellence (NICE), September 2007. www.nice.org.uk
- Hospital episode statistics. NHS Maternity Statistics – 2012-13. Health and Social care information Centre. www.hscic.gov.uk, published 13 December 2013
- Map of Medicine. Normal birth. International View. London: Map of Medicine; 2013 (Issue 1)
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- Induction of labour. National Institute for Health and Clinical Excellence (NICE), April 2014. www.nice.org.uk
- Olsen O, Clausen JA. Planned hospital birth versus planned home birth. Cochrane Database of Systematic Reviews 2013, Issue 11. doi:10.1002/14651858.CD000352.pub2
- Birthplace in England Collaborative Group. Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study BMJ 2011; 343:d7400 (2011)
- Cluett ER, Burns E. Immersion in water in labour and birth. Cochrane Database of Systematic Reviews 2009, Issue 2. doi:10.1002/14651858.CD000111.pub3
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Reviewed by Dylan Merkett, Bupa Health Content Team, November 2014.
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