Understanding Stages of Labor

Third Trimester

Feb 13

Every birth is different and there is a wide range of what is considered “normal”. Before diving into the details about labor, let’s dispell a few myths created by depictions of birth in movies/TV:

Movies vs. Reality

Myth: labor starts dramatically with water breaking

Reality: labor is a very long process that usually starts off slowly and subtly with light contractions spaced far apart. For the vast majority of women (~ 90%), water breaks later, after labor has already begun.

Myth: once you’re in labor, it’s time to frantically rush to the hospital

Reality: the first stage of labor can take hours or even days, and it’s best to be at home for this. Hospitals will not admit you until you’re further along.

Myth: labor is mostly about pushing, and it is the most painful part

Reality: the contractions in active labor and transition are typically the most painful part, and last much longer than the pushing phase.

Myth: there is lots of high pitched screaming during labor/birth

Reality: it is much more common to deal with labor pain with low-pitched moaning or groaning sounds. Grunting, panting or slow loud exhales may also occur. And because labor pain is intermittent and you get breaks between contractions, there will be quiet periods too.

Myth: you’ll spend most of your labor lying on back, legs in stirrups

Reality: most women actually try lots of different positions throughout labor and birth, including kneeling, all fours, sidelying, squatting, etc

Overview of Stages

There are three main stages of labor:

First Stage: divided into Early Labor, Active Labor and Transition
Second Stage: Pushing & Birth
Third Stage: Delivery of the Placenta

The below graph summarizes these stages, with more details in the sections that follow.

For the lengths of each stage, first-time moms will be at the higher end of the averages
Everyone defines the cut-offs for dilation and contractions for the different phases slightly differently - the general pattern matters more than the specifics here


Stage	Description	Length	Dilation	Contractions
Early Labor	Longest and least intense phase, so sleep if you’re able or do light chores or relaxing activities	Hours to days, even weeks	0-3 cm	Start up to 20 min apart; get to 4 or 5 min apart; Last 30-45 secs
Active Labor	You’re no longer able to talk through contractions and must focus on breathing	3-8 hrs	4-7 cm	Every 3-5 min Last 45-60 secs
Transition	Most painful part (no break between contractions and may start shaking), but usually short	15 mins - 2 hrs	8-10 cm	Every 2-3 min Last 60-90 secs
Pushing	You’ll feel urge to “bear down” and push during contractions, and then rest in between	15 mins - 2 hrs	10 cm	Start to ease up - further apart and less painful
Placenta	Mostly an afterthought because you’re distracted by your new baby, but may require a short push to expel	5-10 mins		Mild to none

Early Labor

When does labor officially begin?

In the final weeks of pregnancy, you may start having cervical exams where your OB will check to see if there are signs that labor may start soon. They are looking for:

Dilation - is your cervix starting to open up?
Effacement - is the cervix thinning out and shortening?
Ripening (weird word I know) - is the cervix getting softer?
Station of the baby - is the baby starting to drop lower?

Progress on these measures might mean that labor is coming soon, but it’s not a guarantee so resist the urge to read too much into this
If labor hasn’t started and you’re past your due date, you may begin talking about scheduling an induction - more info on that process here
Mucus Plug/Bloody Show: another sign that labor may be imminent is when you release a big clump of mucus (more than normal vaginal discharge), which may be tinged with blood. During pregnancy, this mucus had been blocking the opening of the cervix to protect the fetus from bacteria. As you start to dilate and efface, it can become dislodged.
Labor “officially” begins once you are having regular contractions. Everyone talks about contractions like we should know what that is, but what exactly is it and how does it feel?

This is when the muscles of your uterus tighten up, literally shortening (e.g. contracting) the uterus in order to push the baby downward and help the cervix to expand
Your abdomen hardens and you feel a wave of pain that rises and falls. During the periods between contractions, you feel almost complete relief and peace (plus your body is flooded with endorphins and oxytocin, which help counteract the pain)
You may feel contraction pain in your back or butt as much as your uterus
In the beginning, it may feel like a strong period cramp, but it will get a lot more intense

Compared to Braxton Hicks (or “practice contractions”) that you may feel intermittently during your third trimester, labor contractions are:

More consistent, with the intervals getting smaller over time
More painful (though early on it’s a manageable pain that you could talk through)
Felt in a broader area (e.g. the whole uterus, not just one section)

What should I do during early labor?

Rest and fuel up

If labor begins at night (as is often the case) and isn’t too intense, I’d resist the urge to wake your partner and instead let them sleep until things pick up and you really need them - better to have them rested for the later stages!
Some ideas for relaxing activities you can do: listen to music or mediations, do a puzzle, watch a movie, take a bath, go on a walk
Cuddling with someone you love can increase your oxytocin levels, which help move labor along!
Have some food and water- you will need energy to make it through labor, but it will become more difficult to eat later on

Practice your techniques

Don’t start too early, because it could be hours and you don’t want to burn out, but once contractions are 6-7 minutes apart and pain is more noticeable
It can be beneficial to start utilizing whatever breathing, visualization or counter-pressure techniques you’ve planned while things are relatively easy, to get in a groove before contractions intensify

Count contractions

Contractions are measured from the beginning of one contraction to the beginning of the next
Have you partner download a contraction timer app or just use the stopwatch function on their phone, noting the start and stop time of every contraction to get their frequency and duration
When we say that contractions are 4 minutes apart, it isn’t 4 minutes of rest in between - since the contraction itself lasts 1 minute, it’s really only 3 minutes of rest in between
The rule of thumb for when to go to the hospital is some version of the 4:1:1 rule

You’re having contractions 4 minutes apart, lasting at least 1 minute, and this pattern has held for at least 1 hour
Some people choose to go sooner at 5:1:1, others stay home longer until 3:1:1
Other reasons to head to the hospital: heavy bleeding (a pad an hour), water breaks and it’s green/yellow, feeling any pelvic pressure/heaviness like you have to poop

Active Labor & Transition

Arriving at the Hospital:

You will likely head to the hospital soon after labor becomes “active” and is more painful, but the longer you can stay at home the better, as labor typically progresses more easily in the comfort of your home
Active labor may feel more inward, like you’re a little “out of it” and it’s hard to talk
The logistics of getting to and registering at the hospital, and the general atmosphere of a hospital, can stall the progress of labor; try to stay “in the zone” as much as you can. A couple tips that can help:

Delegate all comms to your partner: updating friends/fam with texts, communicating with hospital staff, filling out forms
Wear headphones and listen to rhythmic music that can help you with breathing timing
Have the nurses to turn the lights down in the Triage and Labor rooms

You will first go to “Triage” where they will assess whether you are far enough along to be admitted - this means measuring your contractions and dilation (usually 4-5cm+ to be admitted), and checking baby’s heart rate

In Labor Room:

If admitted, you will move into the labor room and meet a new set of nurses - if you have a printed birth preferences/plan, your partner or doula can share it with them
This is now your room, so do whatever you want to make it more comfortable - dim the lights, use a diffuser, put on music, etc. If you’re able to hear noises from other rooms and it’s distracting, consider putting on some white noise.
You will be connected to a fetal monitor and will see your contractions displayed on a screen - ask for the wireless kind of monitor, which allows for greater freedom of movement
If you are GBS positive, you will begin to receive antibiotics through an IV

GBS (Group B Strep) is a common bacteria that 25% of pregnant women have; it’s harmless to mom, but can be dangerous to baby so you will receive antibiotics to prevent it from being spread. You’ll be tested for GBS around week 35-37.

You will continue to have stronger and stronger contractions that increase dilation, hopefully at a rate of 1-2 cm per hour
Experiment with different positions, moving during the rest between contractions: many women (myself included!) are surprised to find that sitting on the toilet is a favorite position. Try the shower/tub or birth ball if it’s speaking to you.

Moving positions may feel daunting in the moment, but sometimes it’s just what your body needs to make progress

Your partner or doula can help you cope with the labor pain through counter pressure and massage (read more about this support here)
As the pain intensifies, you’ll find that you lose all niceties in your communication and you may speak in one word commands (“more”, “stop”). Give your partner the heads up beforehand that this is a common phenomenon so they’re prepared and won’t take it personally :)
Consider requesting medical pain relief - read here about all the pain relief options available at the hospital (epidural, nitrous oxide, and opioids). You can ask for an epidural at any point in active labor, but know that it may take 30-45 minutes for the anesthesiologist to come and get it set up, so I wouldn’t wait until you’re at a breaking point.
At some point, your water will break (i.e. amniotic sac breaks) if it hasn’t already- sometimes this is an unmistakable gush of fluid, other times it may be more intermittent leaking. It is totally painless. If it doesn’t break on its own, the doctors may need to rupture it themselves.
The doctors will perform a cervical exam to check on the progress of dilation - you can ask to minimize the number of exams, or request additional ones. The results can feel very motivating or disheartening depending on how much progress has been made.
The final couple centimeters (“transition”) are the most difficult as you have very little break in between contractions
Once the cervix is fully dilated at 10cm, there’s a bit of a lull in contractions…it’s like your body is giving you a break before the next stage - pushing!

Pushing and Delivery

Your doctor will tell you once it’s time to push - pushing too soon before you are fully dilated can cause tearing in the cervix
If the baby isn’t low enough in the birth canal, you may be told to wait to push and instead “labor down” - which means allowing contractions and gravity to bring the baby further down before actively pushing. It may be hard to not push if you’re feeling a strong urge to bear down, but panting quickly and then blowing out (like you’re blowing birthday candles) can help.
Pooping during this stage of labor is common and not a big deal - think about it as freeing up more space for baby to move down
If you’ve had an epidural, you won’t feel the pushing urge naturally but just try to engage the same muscles you use when pushing out a poop!
Ask for a mirror during this phase if that sounds appealing - it can be very motivating to see the progress your pushes are creating, as you start to see the baby's hair and head. It can be especially helpful if you’ve had an epidural and thus aren’t getting as much sensory feedback.
Your OB may coach you on how to time your pushes with the contractions - typically, you take a deep breath at the beginning of the contraction, hold it, and then push for a count of 10, repeating this 2-3 times per contraction. You can also choose to just follow your intuition about when and how to push if that feels right.
The baby will likely recede back a little bit in between pushes - it’s a “three steps forward, one step back” kind of situation and that’s normal
If pushing isn’t working, is taking too long, or baby is in distress, delivery assistance interventions may be required (vacuum, forceps and C-section)
Crowning - when the baby’s head starts to come through - can cause intense burning or stinging sensation as it stretches (and often tears) your perineum. This is sometimes called the “ring of fire” and can be the most painful part of birth but is thankfully short.

As part of your birth preferences, request that the nurses provide warm compresses and counter pressure to the perineum to reduce pain and tearing

After the baby’s head comes out, the rest of the body follows easily and quickly, and before you know it, a slimy, gray-blue, crying newborn will be plopped on your chest for that first sweet skin-to-skin

Read about Newborn Medical Decisions - like delayed cord clamping, Erythromycin, etc.

Placenta

The last stage is when the placenta separates from the uterus and is expelled - this usually happens 5-15 minutes after the baby is born
The OB may pull on the umbilical cord or push gently on your abdomen to help expel the placenta
Pitocin may also be administered at this stage - it helps the uterus contract to push out the placenta and stop the bleeding
Once the placenta is out, take a moment to marvel at this massive organ that has been sustaining your baby all these months!

I don’t recommend keeping it for encapsulation - there isn’t good evidence of any benefits, and it could make you sick

While uncommon, if the placenta does not come out fully as one piece, or is taking a long time (over 30 mins), there is risk of infection or hemorrhaging. The doctor may try to remove it manually, administer more medication, or wait to see if breastfeeding helps expel it because it can cause further contractions
If you had any tearing during birth - perineal or labial - they will also now stitch you up

Sophie Smith