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The Stages of Labor and Delivery

Almost everyone has heard a story about labor. These grand but true tales of childbirth and how we survived it are one of the many marks of motherhood. My daughter enjoyed her cozy space. She was six days past her due date and was delivered via cesarean section some 36 hours after I began labor. The experience was great for new resident doctors. With one patient they could see first-hand the effects of a multitude of pain medicines and an epidural, the beginnings of a vaginal birth, some mild distress of a baby whose head was in the wrong position and finally a Cesarean delivery. The stuff textbooks are made of.

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The stories are great but not all labors are like that. Ease of labor and delivery is like running. By staying in the moment and taking one step at a time, the end result is quite fulfilling. Knowing beforehand what is to be expected is a good idea.

Early Signs of Labor in Pregnancy: The First Stage

The earliest signs of labor and delivery are uterine contractions, cervical dilation and often nausea and vomiting. Some women have contractions as early as thirty weeks into the pregnancy. These contractions often occur randomly and are usually painless. They are called Braxton Hicks contractions.

Braxton Hicks contractions are considered false labor and are not a sign of early labor. Braxton Hicks contractions can cause pressure, but don't have the same intensity as labor contractions. Labor contractions are very distinct and intense. Most doctors tell women to come into the hospital once the contractions are regular and five minutes apart. Intensity of the contractions is specific to each pregnancy.

The 5-1-1 Rule
This rule will help you determine when it's time to go to the hospital:

Your contractions are 5 minutes (or less apart)—that's from the beginning of one contraction to the beginning of the next.
Each contraction lasts at least 1 minute.
The contractions have had this pattern for at least 1 hour.

Inducing Labor

Labor induction may be required for women who have significantly exceeded the due date or those whose contractions are not strong enough to continue with labor. Inducing labor involves the delivery of intravenous medication to encourage contractions. Prostaglandins are administered to "ripen the cervix" and oxytocic agents like Pitocin promote strong and effective contractions.

Determining Fetal Lie

Once in the labor and delivery ward, the doctor or health practitioner will perform an exam to confirm the fetal lie. The fetal lie refers to the position of the baby's spine in relation to the mother's. The most common position is known as vertex or cephalic where the spines are parallel and the baby's head is facing downwards.

When the baby is angled (oblique lie) or at a right angle to the mother's spine (transverse lie) potentially serious birthing complications such as cord prolapse, when the umbilical cord is birthed before the baby, can occur.

Occasionally, a baby will be turned around so that the head is furthest from the opening of the birth canal. This type of birth is a breech birth. A breech birth is a sign of a difficult delivery and may require repositioning of the baby or Cesarean section.

Cervical Effacement and Dilation

The doctor will also determine what changes are occurring in the cervix. Changes in the cervix are a sign that the baby is getting ready for the journey through the birth canal.

As contractions continue the cervix thins out. This stretching and thinning of the cervix results as the cervix opens wider or dilates. The first stage of labor is complete when the cervix dilates to ten centimeters, a process that can take up to twenty hours in first births and as little as eight in subsequent births.

Definitions
Effacement: Measured as a percentage this is the thickness of the cervix; 50% effaced means the cervix has "thinned" half way; 100% effaced means the cervix has thinned all the way.

Dilation: Measured in centimeters this how much the cervix is opened; the cervix is fully closed at 0cm and fully open at 10cm.

Rupturing the Membranes

The doctor will also look to see if the membranes have been ruptured. Ruptured membranes or "breaking of the water" refers to the amniotic sac breaking as the baby pushes into the birth canal. If labor is induced or the sac has not yet broken, the doctor can manually rupture the membranes.

Second Stage of Labor

The second stage of labor occurs once the cervix is fully dilated and effaced. This stage includes pushing the baby and the actual delivery of the baby and can last up to three hours in a first birth and as little as thirty minutes in women who have previously given birth. This stage can also be prolonged in women receiving epidural anesthesia. The epidural anesthesia reduces pain and sensation during the pushing phase.

Third Stage of Labor

Once the baby has been delivered the third stage of birth begins. This stage is the delivery of the afterbirth or placenta. Many women are distracted by their babies at this stage and rarely notice this process.

This stage can be as short as five minutes. A retained placenta, a placenta that must be removed by the doctor or birth attendant, could cause this stage to last up to thirty minutes.

Resources

Beers, M.H. & Berkow, R. (ed). Normal pregnancy, labor, and delivery. The Merck Manual of Diagnosis and Therapy, 17th Edition. Merck Research Laboratories, NJ, 1999.

Callahan, T.L., Caughey, A.B., Heffner, L.J. (2001). Blueprints in Obstetrics and Gynecology, 2nd Edition. Blackwell Publishing, MA.

WebMD. (updated 2001). What to expect during each stage of labor.

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