Pregnancy, Childbirth, and the Newborn: The Complete Guide, 4th Ed.

CHAPTER 12 What Childbirth Is Really Like

When your labor begins, all the information you’ve gathered and the plans you’ve made will suddenly merge with the reality of childbirth, a physical and emotional experience that’s often unpredictable and uncontrollable. You’ll be glad you took the time during pregnancy to learn about giving birth and to figure out your preferences and needs. This chapter describes the sequence of events that occurs in a normal, healthy labor and birth. It also discusses steps you can take to respond to any variation in labor, from a rapid labor to a prolonged one.


In this chapter, you’ll learn about:

• The four stages of labor, including what you can expect physically and emotionally in each one

• What you can do to help your labor progress and make it more comfortable

• Ways that your partner, doula, or other support people can help you

• Normal variations in the length of labor, and ways to manage the unique challenges of a slow or rapid labor

Stages and Phases of Labor

Labor marks your baby’s transition to an independent existence and your transition to parenthood. Even before labor begins, changes occur that prepare your body for it. During prelabor, which may last for days or weeks, your cervix moves forward, ripens (softens) and effaces (thins or shortens).

Over the course of labor, your uterus contracts, your cervix continues to ripen and efface and begins to dilate, your baby rotates and moves down your birth canal, and you give birth to your baby, placenta, umbilical cord, and amniotic sac. The entire process (excluding prelabor) can take anywhere from a few hours to a day or longer.

Labor is divided into four stages, each of which marks a sign of progression. The first and second stages are further divided into phases, which represent more subtle changes than the stages.

The first stage of labor (dilation) begins with contractions that are becoming longer, stronger, and more frequent (that is, progressing) and ends when your cervix is completely dilated. It has three phases: early labor, active labor, and transition. The second stage of labor (birth of your baby) begins when your cervix is fully dilated and ends when your baby is born. The third stage of labor (delivery of the placenta) begins with the birth of your baby and ends with the delivery of the placenta. Lastly, the fourth stage of labor (recovery) begins after the placenta is delivered and ends one to several hours later, when your condition has stabilized.


First Stage of Labor: Dilation

When your contractions are progressing and your ripening, effacing cervix begins to dilate, you’re in the first stage of labor. Dilation increases with each phase of this stage, until your cervix is about 10 centimeters in diameter. In early labor, your cervix dilates to 4 or 5 centimeters. In active labor, it further dilates to 8 centimeters, and in transition, it completely dilates to 10 centimeters. As labor progresses, each successive phase usually becomes shorter and more intense than the previous phase. Each phase has recognizable characteristics that present unique physical and emotional challenges.

The first stage typically lasts between two and twenty-four hours. For a first-time mother, the average length of the first stage is twelve and a half hours. For a woman who has given birth before, the first stage usually lasts half that amount of time (if labor wasn’t induced).

For some women, the first stage may be much slower or quicker than average. See pages 245 and 247 to learn more about handling the challenges of a prolonged labor or a rapid labor.

Common Q & A

Q: My mother said labor went by pretty quickly when she gave birth to me. Will my labor progress as fast as hers did?

A: It might—or it might not. The answer depends on many variables, including whose body build and other characteristics you inherited, your overall health, and characteristics that your baby inherited from his father.


Throughout the phases of the first stage, your contractions become increasingly intense. But what exactly is a labor contraction? By the end of your pregnancy, your uterus has become the largest and strongest muscle in your body. When it contracts, it hardens and bulges like any other muscle does, and the muscle fibers shorten and pull your ripe, effaced cervix open. The sensation you feel during this process may be mild and uncomfortable or it may be intense and painful.

Contractions are involuntary; you can’t control them. Each contraction follows a wavelike pattern: It builds to a peak, then gradually disappears, allowing your uterus (and you) to rest. The frequency of contractions increases until your cervix is completely dilated.

In early labor, contractions usually feel like dull lower back pain or abdominal cramps. Very early contractions are usually short and mild, lasting thirty to forty seconds, and the time between them may be as long as fifteen or twenty minutes. These contractions may make it difficult to tell whether you’re in labor or still in prelabor. (See Chapter 9.)

As labor progresses, contractions become markedly stronger and longer. By the end of the first stage, contractions usually are very intense and last as long as ninety seconds to two minutes. When trying to cope with the intensity of labor, it helps to remind yourself that every contraction has an end. The time from the beginning of one contraction to the beginning of the next may be as short as two or three minutes, allowing you just a brief rest between contractions.

Hormones in Labor

Before, during, and after labor, your body produces several hormones, including:

• Oxytocin, the “love hormone,” which plays a major role in orgasm, breastfeeding, and childbirth. In labor, it causes contractions and helps with progress.

• Stress hormones (catecholamines), which counteract oxytocin and can slow contractions, leading to a prolonged labor.

• Beta-endorphins, your body’s painkillers, which are secreted when you experience pain, stress, and physical exertion. They help you transcend pain and enter a trance state that’s sometimes called the “birth zone.”

• Prolactin, which is produced after the birth. It’s necessary for milk production, and it calms and elevates your mood.

To decrease stress hormones and increase oxytocin and beta-endorphins during labor, the following are essential: confidence, a sense of safety, privacy, quietness, familiar places and faces, supportive interactions with others, and feeling loved (and reciprocating that feeling) through touch, massage, kissing, and caressing. Conversely, the following increase stress hormones and decrease oxytocin and beta-endorphins: anxiety, fear, anger, decision-making, frequent disturbances, and feeling watched or judged.

For more information about hormones and optimal hormonal interactions, read Gentle Birth, Gentle Mothering: A Doctor’s Guide to Natural Childbirth and Gentle Early Parenting Choices by Sarah Buckley and Ina May Gaskin (2008).


First Phase: Early Labor

Early labor or the latent phase is usually the longest phase in the first stage, often because contractions are further apart, shorter, and less intense than they’ll be later in labor. During early labor, your cervix becomes fully effaced and dilates to 4 or 5 centimeters. You’ll probably spend most of this phase at or near home, keeping busy or relaxing if it’s daytime and resting if it’s nighttime. Because this is the “waiting and wondering” phase, review Chapter 9 and use the Early Labor Record on page 175 to help you decide whether you’re in early labor or still in prelabor.

The best way to cope with early labor is to ignore the phase until your mind or body no longer lets you. At that point, use coping techniques, such as those discussed on page 243, to help you enter a confident, optimistic state of mind. This mind-set can influence the interactions of hormones in a way that optimizes labor progress (see above).1


Getting through Early Labor

When you begin early labor, you may feel excited and a bit nervous. You’ll probably want your partner near so he or she can provide support, now that labor feels real to you. The key to coping with this phase is to avoid assuming your labor is progressing much faster than it really is. Try not to focus too much on each contraction. In fact, if you can ignore these early contractions, do so! Becoming preoccupied with early contractions often has the unwelcome effect of making your entire labor seem longer than you were anticipating.

During early labor, rest if you’re tired or if it’s nighttime. Otherwise, try to keep busy doing activities that are fun, calming, or distracting (but not exhausting). Here are some activities that may appeal to you in early labor:

Two Views on Getting through Early Labor

The first contraction woke me at 3:25 am. For most of that day, I had a contraction every ten minutes or so. The pain was mild, so my husband and I thought it was best just to go about our business as though it were any other day. We returned a rented DVD, ran errands, ate a nice meal, and napped. It was a relaxing time.


My first contractions weren’t very strong or frequent. To take my mind off the contractions, I took a shower, walked my dog, watched a movie, and just tried to relax. That night, after an entire day with little change in my labor, I tried to slow down the contractions with a bath so I could sleep. The bath helped, and I slept off and on for several hours.


• Pack your bag to take to the hospital or birth center (see page 166) or prepare your home if you’re planning a home birth.

• Meditate or use guided visualization.

• Have a massage. During contractions in early labor, it’s natural to tense specific areas of your body, or tension spots. Tension increases your perception of pain, so releasing tension with early contractions gets you into the habit of relaxing your muscles for later phases, when contractions will be more intense. See page 215 to learn how you and your partner can recognize and release muscle tension.

• Take a long shower (but not a bath—see page 210).2

• Consume easy-to-digest foods and drinks that appeal to you, such as soup, broth, and herbal tea, as well as high-carbohydrate foods such as fruit, pasta, toast, rice, and waffles.

• Go for a walk, visit with friends, listen to music, write in your journal, e-mail relatives, watch a movie, dance, or play cards or other games.

• Do a preplanned “early labor project,” such as working on a hobby, gardening, laundering and sorting your baby’s clothes, preparing one-dish meals to freeze and enjoy after the birth, or baking a birthday cake to welcome your new arrival.

When to Go to Your Birthplace or Call Your Midwife

At some point, as early labor progresses, you’ll begin thinking about going to the hospital or birth center, or calling your midwife to come to your home. Because you may have trouble determining your progress, during your last month of pregnancy your caregiver will tell you when and whom to call if you think you’re in labor. Depending on your caregiver and birthplace, you may call the hospital maternity unit (especially at night), an answering service, or your caregiver’s direct line.

Your caregiver probably will recommend that you use the following guidelines when deciding whether to call:

• If this is your first baby, call when your membranes rupture (or may have ruptured), or follow the 4-1-1 or 5-1-1 rule. This rule means that your contractions are intense enough to require you to focus and breathe rhythmically, and are four or five minutes apart, each lasting at least one minute for a period of one hour. Whether you follow 4-1-1 or 5-1-1 depends on your caregiver’s advice and how long it takes you to get to your birthplace or for your midwife to come to your home.

• If you’ve given birth before, call your caregiver or hospital maternity unit when your membranes rupture or when you’re having progressing contractions and other signs of labor (for example, you have bloody show, soft bowel movements with contractions, and so on). Because you’ve given birth before, you’re likely to quickly shift from early to active labor. Consequently, you don’t necessarily need to wait for 5-1-1: You may be advised to go to the hospital or birth center as soon as your contractions are five minutes apart.

• If you have a condition that requires hospital observation during early labor, call whenever you suspect labor. Examples of such conditions include positive Group B streptococcus (GBS), a herpes sore, and any high-risk condition. See Chapter 13 for more information on these potential complications.

• Regardless of the status of your labor, you may always call your caregiver or the hospital maternity unit if you’re anxious, have questions, live far from the birthplace (or your home birth midwife lives far from you), or have received specific instructions to call before labor is established.

When you do call, be ready to report the following information that you’ve noted in your Early Labor Record (see page 175):

• How long your contractions last (duration)

• How many minutes apart they are, from the start of one to the start of the next (interval or frequency)

• How strong the contractions seem (intensity)—can you talk through them or do you need to use your planned ritual?

• How long your contractions have been like this

• Status of your membranes—have they ruptured? Is there a color or strong odor to the fluid?

• Presence of bloody show

• Other information that will help your caregiver (or the on-call caregiver) know about you and your pregnancy

The nurse or caregiver who takes your call uses this information to determine whether to tell you come to the hospital or birth center, or recommend that you stay home until further changes have occurred (for example, until your membranes have ruptured or your contractions become longer or occur closer together). If you’re having a home birth, your midwife uses this information to decide whether to come to your home immediately or later, when your labor has further progressed.

The Three Rs: Relaxation, Rhythm, and Ritual

After several hours (or even a day or longer) of prelabor and early labor, you’ll at last reach a point when you’re unable to ignore your contractions. You can’t walk or talk through a contraction without having to pause at its peak. Activities are no longer distracting or fun. This point marks a shift in your coping strategy. Instead of using distracting activities to cope with contractions, you instead begin using the Three Rs: relaxation, rhythm, and ritual. See page 206 for a full discussion on the Three Rs.

A Note to Fathers and Partners

Early labor is an exciting time for you as well. Try to spend it constructively. Contact your laboring partner’s caregiver and doula. If the birth will occur in a hospital or birth center, make sure her bags (and yours) are packed and stowed in your vehicle, and check that there’s enough fuel in the tank. If you’re planning a home birth, make sure you have the birth supplies that the midwife requested, as well as enough food and beverages for everyone. Have comfort items ready and accessible. Tidy up your home so your partner and the midwife can move about during labor without having to navigate around messes and clutter. Make sure your vehicle has enough fuel, in case a transfer to the hospital is necessary.

Help your partner through early labor contractions by following her lead. If she becomes quiet and uncommunicative during contractions, you should also become quiet. Don’t ask her questions and try not to act more excited than she is. However, if she becomes chatty, active, and excited between contractions, respond to her in kind.

Be aware of how she’s coping during contractions, but don’t hover or stare at her—this may have the unintended but annoying effect of making her feel watched. If you notice that she’s tensing any area of her body during a contraction, alert her of the tension by firmly touching the tense area, or by telling her about the tension between contractions in a gentle, nonjudgmental way. For example, you may say, “I noticed you seemed to tense up in your shoulders with that contraction. With the next one, try to breathe away any tension in your shoulders with each exhalation.”

In general, look for rhythm in her breathing and movements during contractions, and try to match her rhythm with your touch, movements, and voice. Remind her to sip water after every contraction or two. See Appendix B for suggestions on ways you can help your partner throughout labor, and see Chapter 11 for more information on relaxation techniques and comfort measures. Working with your partner during early labor contractions will pay off later, when her contractions become more challenging.


Sometimes, labor is prolonged; that is, it takes a long time to get started. If early labor seems slow, you may wonder whether you’re truly in that phase yet. It can be difficult to distinguish between a long prelabor (in which your contractions aren’t progressing and your cervix isn’t dilating) and a slow early labor (in which contractions and cervical dilation are progressing slower than usual for this phase).


How much time must pass before early labor is considered prolonged? One theory claims that early labor is prolonged if regular contractions continue for longer than twenty hours.3 However, many caregivers believe that if early labor is taking a physical or psychological toll on the woman, it’s prolonged—regardless of the amount of time that has passed in the phase.

If your early labor is prolonged, you may become tired and discouraged, but don’t assume that your entire labor will be slow. Prolonged early labor is not a labor complication. In most cases, labor progresses normally as soon as it reaches the active phase.

In a prolonged early labor, it’s important to figure out the cause so that you, your partner or doula, and your nurse or caregiver can take action (if possible) to speed up your progress. The following are the most probable causes for a prolonged early labor:

• Your contractions have begun before your cervix has moved forward, ripened, or effaced—the changes that prepare it for dilation. (See page 169.)

• Your cervix is scarred from a previous surgery, cone biopsy, or another cervical procedure. For your cervix to dilate, it may require many frequent and intense contractions to overcome the resistance caused by the scar tissue.

• Your baby is malpositioned, such as occiput posterior (see page 285) or with a raised chin. You may also have back pain. Your contractions may seem irregular or they may couple (occur in pairs, with a short break between the first and second contractions).

• You’re tense, anxious, or distressed, all of which increase the levels of stress hormones that can hinder labor progress (see page 242). Several factors can cause stress, including a previous unresolved emotional or physical trauma, a previous difficult birth experience, grief from a miscarriage or abortion, a stressful relationship (with your partner, caregiver, or relatives), and fears about your or your baby’s well-being.

What You Can Do

If early labor is prolonged, the following are suggestions to help you cope mentally and physically as you wait for your labor to progress.

• When you have a vaginal exam, ask your caregiver whether your cervix has moved forward and is ripe; also ask how much it has effaced. If your cervix hasn’t changed much, you need patience and stamina to allow early contractions to complete these changes before they can dilate your cervix.

• Try not to become discouraged or depressed by your slow progress. Visualize your contractions bringing your cervix forward, then ripening and effacing it. Try to accept a prolonged early labor as temporary and appropriate for your body at this time.

• Nurture yourself with food, drink, and loving support.

• Alternate doing labor-stimulating activities with restful, distracting activities (see page 243).

• Don’t time every contraction. Instead, time six contractions in a row, then wait until the pattern of your contractions has changed before timing another series.

• If you have irregular or coupling contractions (occur in pairs with a short break between the first and second contractions) or back pain, assume that your baby isn’t in an ideal position for birth. Use the techniques described on pages 229–232 to relieve back pain and move your baby into an ideal position. Once your baby is in a better position, back pain should dissipate, your pattern of contractions should improve, and labor progress should speed up.

• If you’re worried or tense, talk with your partner, caregiver, or other supportive person. He or she may be able to help you put your concerns into perspective. If all else fails, having a good cry—in private or with a compassionate companion—can help release any overwhelming sadness or anxiety.

Note: If you know or suspect that you’ll be very worried or tense in labor, talk with your caregiver, doula, counselor, or childbirth educator during pregnancy to help you identify and address any potential sources of stress. Together, you can plan ways to cope with the stress during labor, such as using relaxation techniques and slow breathing to calm yourself (see Chapter 11).

In Their Own Words

After ten hours of mild contractions that were six minutes apart, I called the hospital to see if I could come in for medication to help me sleep. An examination showed that my cervix was 3 centimeters dilated and 100 percent effaced. My midwife gave me three options: get a morphine shot and go home to sleep, get the shot and sleep in an unused room upstairs, or be admitted and get an epidural. I chose to get the shot and go home, where I was able to sleep for a couple hours. When I woke up, contractions were strong, so I headed to the hospital. My cervix was 6 centimeters dilated, so I was admitted.


Medical Care for a Prolonged Early Labor

Despite your best efforts to cope with a prolonged early labor, if you become exhausted or have made little or no progress for more than twenty-four hours, you and your caregiver may need to decide whether to turn to medical interventions. There are two major approaches to speeding up a labor medically:

1. Using medications to stop contractions or to help you rest. Your caregiver may recommend drugs such as tranquilizers, sedatives, uterine relaxants, morphine, or alcohol.

2. Using medications or procedures to stimulate more effective contractions. Your caregiver may suggest stripping your membranes, mechanically ripening or dilating your cervix, breaking your bag of waters, ripening your cervix with prostaglandins, or inducing labor with Pitocin. (See pages 279–283.)

These medications and procedures can affect your baby and have undesired side effects for you, so they shouldn’t be used without good reason. To help you make an informed decision, ask your caregiver the key questions about the risks and benefits of these options (see page 10). Your decision depends on your stamina and your willingness to continue. If you and your baby are doing well and you feel you can continue coping on your own, let your caregiver know. However, if you feel too exhausted or discouraged to continue on your own, request medical help.

If scar tissue on your cervix is causing a prolonged and very painful early labor, you likely need medical help. Your caregiver may quickly massage your cervix open a few centimeters. If this procedure is successful, your cervix begins dilating, and your labor progress may then continue normally. The procedure is painful, and you may need to follow the Take Charge Routine (see page 256); if it’s unsuccessful, you may need narcotics or other pain medications.


Some women—especially those who’ve given birth before—have rapid labors. These labors begin with contractions that are only three or four minutes apart, and become increasingly stronger, longer, and more frequent than usual. If your labor progresses this quickly, see page 301 for more information on what to do.

Second Phase: Active Labor

When your cervix is dilated to 4 to 5 centimeters, your contractions usually reach the 4-1-1 or 5-1-1 pattern (see page 244). At this point, you’re shifting from early labor to active labor. During this phase, dilation usually speeds up, contractions typically become painful (but manageable), and labor progresses with each contraction. Most expectant couples go to the hospital or birth center in this phase, or await the arrival of their home birth midwife.

Getting through the Active Phase

Active labor may be emotionally challenging for you. Your contractions have intensified and require your full attention to manage. You may feel discouraged when you think about how long it’s taken your cervix to dilate just halfway and may assume it’ll take the same amount of time for your cervix to dilate to 10 centimeters. (It won’t; dilation typically speeds up in active labor.) You may feel trapped, as you realize that your contractions are beyond your control and will continue to intensify until your cervix is fully dilated. You may weep because you feel overwhelmed. These reactions to this demanding phase are normal.

Although active labor can be challenging, you’re not doomed to suffer through it. You can manage this phase (and cope better afterward) if the following are true:

• You’re allowed to labor in an environment that fosters privacy, preserves your modesty, and minimizes disturbances. When you’re undisturbed, you can focus inward and find your spontaneous rituals (see page 207) to help you get through contractions.

• You have support people who unconditionally accept your coping style and assist you whenever needed. In this phase, you become serious, quiet, and preoccupied. During contractions, you require your partner and others to focus on you—they shouldn’t talk among themselves or to you, unless you request a response. (If you feel that someone isn’t acting in a way that contributes to your emotional well-being, ask that he or she leave the room.)

• You have the freedom to move about and seek comfort in whatever ways you find helpful.

If giving birth in a hospital or birth center, traveling to the site during active labor creates a major disturbance in your coping strategy. A good way to prepare for this disruption is to practice comfort techniques (see Chapter 11) in noisy, busy environments before labor. That way, you may be able to continue coping during the ride and the admitting procedures as best as you can (see page 249 for suggestions), then return to your ideal focused state once you’re settled in your room—assuming, of course, you’re not being watched, judged, or told how to behave.


A Note to Fathers and Partners

Figure out how to help your laboring partner by following her lead. Just as in early labor, be attentive to her in active labor, but don’t disturb her. If she wants silence during contractions (or all the time), keep quiet. Match her mood. Observe and support her ritual during contractions (see page 207). She may want you to help her cope by slow dancing or walking with her, stroking her, moaning with her, matching her rhythm by swaying or by moving your hand or head, keeping eye contact with her, or counting her breaths. Or she may be so inwardly focused that she wants only your calm presence, perhaps allowing you to hold her hand or offer her sips of a beverage between contractions. See Appendix B for suggestions on ways you can help your partner throughout labor.

If she seems disappointed with her progress, encourage her to be patient and trust that she’s doing well. If you’re discouraged with her progress, take her caregiver or doula aside (so you’re out of your partner’s earshot) and ask about her well-being. Once labor progress speeds up, you’ll both feel encouraged.

In Their Own Words

After a nurse examined me, she said I was still in early labor and told my partner and me to go home and rest. When we got home, I couldn’t sleep and found many tasks to complete around the house. I’d later regret not taking the advice to rest, but keeping active did allow my labor to progress, and I was admitted to the hospital just four hours later.



After you’ve called to report the information in your Early Labor Record (see page 175) and are told to go to the hospital or birth center, make sure you have your bag, your birth plan (see Chapter 8), and any last-minute items (for example, a towel if your bag of waters is leaking) and head to the birthplace. Do not drive yourself; have your partner drive. If you know beforehand that your partner might not be able to drive you, recruit someone else.

The ride to the birthplace may be challenging and uncomfortable. You’ll probably be more aware of every bump and pothole than ever before! Your partner should drive carefully and not speed. Try to think of the trip as a way to confirm whether you need to be at the birthplace. Focus your breathing on something in the vehicle to give you a rhythm to follow. For example, your partner can nod his or her head in rhythm with your breathing or count your breaths.

If giving birth in a hospital, find out ahead of time which entrance to use. If you arrive in the middle of the night, the emergency room may be the only open entrance. Once you’re in the hospital, walk to the maternity unit or use a wheelchair if necessary.

When you arrive at the birth center or the hospital’s maternity unit, an admitting nurse should greet you, then take you either to a birthing room or the triage (observation) area, where she or he assesses your condition, your pattern of contractions, your dilation (with a vaginal exam), and your baby’s well-being. This information helps the nurse decide whether to admit you. If you think your bag of waters has broken, the nurse may give you a sterile speculum exam to obtain a sample of your amniotic fluid for diagnosis. (See page 173 for information on the leaking of amniotic fluid.)

If the nurse decides that you’re still in very early labor, he or she may suggest that you leave the hospital or birth center until your labor pattern changes. You should follow this advice. If you stay at the birthplace, your labor progress is likely to dominate your thoughts, which can make your entire labor seem extremely long. If you leave the birthplace, you can keep busy at home until your labor pattern changes. Also, your labor is likely to progress more readily when you’re in an environment that feels safe, secure, and familiar.

It’s natural to become discouraged when learning that you can’t be admitted to the hospital or birth center, especially if you’re tired and are finding your contractions uncomfortable and difficult to cope with. You may feel concerned, angry, ignored, or frustrated. You may worry that you won’t return to the birthplace in time. If you feel this way, tell the admitting nurse. He or she may be able to reassure you, help you with coping strategies, give you medication to help you rest, or suggest other options if you don’t want to return home (such as taking a walk near the birthplace or going to the cafeteria). As you wait for your labor pattern to change, focus on ways to relax or distract yourself during contractions and on ways to rest between contractions. (See Chapter 11 as well as pages 245–247 for a discussion on prolonged prelabor.)

When you meet the criteria for admission to a hospital’s birth center or maternity unit, you’re taken to your birthing room, where you meet your labor nurse. He or she may assess you in the same way that the admitting nurse did, as well as make other assessments, including taking your medical history, getting urine and blood samples, and checking your baby’s heart rate and position. You change into a hospital gown (or your own) and get an identification bracelet. You may have an intravenous (IV) catheter inserted at this time. The nurse begins monitoring your contractions and your baby’s heart rate (see page 251) for twenty to thirty minutes, typically with an external electronic fetal monitor (see page 252) or possibly with a hand-held Doppler.

In some ways, admission to a freestanding birth center (unaffiliated with a hospital) is similar to admission to a hospital birth center or maternity unit. You’re assessed in the same way; however, your midwife makes the assessments, not a nurse. You also wear your own clothing and don’t receive an identification bracelet.

IV Fluids in Normal Labor

In some hospitals, it’s routine to insert an IV catheter in all laboring women shortly after they’re admitted. In other hospitals, an IV catheter is inserted only if needed—for example, if you need medications such as Pitocin or antibiotics, if you choose to take pain medications, or if you’re unable to keep down enough fluids to stay hydrated.


IV catheters carry a few mild risks; visit our web site,, for more information. In addition, an IV catheter can limit mobility in labor because you’re connected to a wheeled pole that holds the bag of fluids. During a prenatal appointment, ask your caregiver if IV catheters are routine or used only when needed. If they’re routine, ask whether you can instead have a Heparin Lock (or Hep-Lock), which involves inserting an IV catheter, but doesn’t require hooking it to an IV bag and pole until IV fluids are needed.


After you’ve called your midwife and he or she has decided your labor progress warrants coming to your home, your midwife assesses your progress in a way that’s similar to how an admitting nurse makes assessments (see above). Your midwife then brings medical implements, medications, and other essential equipment (such as an oxygen tank) into your home. Depending on your labor progress, he or she may remain with you or may leave your home for a while (but stay within a reasonably close distance). Your midwife may work with an assistant, who remains with you if your midwife leaves for a time during early labor.


After your labor nurse finishes assessing you, make yourself as comfortable as possible. Continue your ritual or begin a spontaneous one (see page 207) to help find your best way to cope. Use comfort measures as appropriate, such as placing pressure and cold packs on your back or hot compresses on your lower abdomen and groin. Empty your bladder every hour or so; a full bladder increases discomfort and can slow labor. Make sure to keep yourself hydrated by sipping water after a few contractions or by sucking on a Popsicle or ice chips.

Try not to lie in bed throughout your labor. Keeping immobile in this position may increase the pain of your contractions and slow labor progress.4 Unless you need to rest or your contractions are coming so fast that you can’t move, try to periodically move about in bed or take advantage of gravity by standing and walking in your room and in the hall. (See pages 221–223 for a discussion of ideal positions for labor.) Note: If you choose to receive pain medications, your mobility may be limited. (See Chapter 10.)


Continue slow breathing (see page 224) for as long as it helps you relax. Switch to light breathing or one of the adaptations (see pages 225–228) if your breathing begins to feel labored, if you can’t keep your breathing rate slow, or if you can’t maintain your rhythm, even after renewed efforts and active encouragement from your partner. Light breathing may be better suited for demanding contractions than slow breathing, just as short, quick breaths are better suited for demanding physical exercise than long, deep breaths are. By tuning in to your contractions, you can adapt your breathing rhythms as needed.


Whether you labor in a hospital, birth center, or at home, expect your caregivers to monitor you and your baby closely, watching for signs of potential problems that may require medical intervention. As long as your labor is normal and your baby is doing well, you don’t need medical procedures. Visit our web site,, for descriptions of techniques used if monitoring indicates that a complication has developed in labor.

Monitoring You

Throughout labor, your nurse or caregiver regularly checks and records your blood pressure, temperature, pulse, urine output, fluid intake, activity, and emotional state. He or she may also perform vaginal exams periodically to determine the effacement and dilation of your cervix and the station, presentation, and position of your baby. These results are recorded on a chart that shows your labor progress. Your nurse or caregiver observes the frequency and intensity of your contractions either by hand or by an electronic monitor (see below). These assessments are all your nurse or caregiver needs, provided that no problems develop in either your labor or baby.

Monitoring Your Baby with Fetal Heart Rate Monitoring

During labor, many things influence your baby’s heart rate: your contractions, his activity (fetal movements), medications, your body temperature, your position, and other factors. The normal fetal heart rate (FHR) range is between 120 and 160 beats per minute. FHR varies within this range in response to changes in the amount of oxygen that’s available. If your baby is handling labor well, he has a “reactive” heart rate, which naturally slows down to compensate for the temporary reductions in oxygen during a contraction and speeds up between contractions. This fluctuation indicates that he’s compensating well to the normal variations in oxygen flow.

Depending on the maturity and health of your baby, his ability to compensate varies. If a lack of oxygen continues over time, his reserves may become exhausted. He might no longer be able to compensate and might become distressed (fetal distress, also known as nonreassuring fetal heart rate or fetal intolerance of labor). When FHR is nonreassuring, close observation and further testing help caregivers identify those few babies who aren’t tolerating labor well and may need immediate medical intervention.

Your baby’s heart rate can be monitored either by auscultation or by electronic fetal monitoring (EFM). With auscultation, your nurse or caregiver listens to your baby’s heartbeat during and between contractions with a Doppler, a hand-held ultrasound stethoscope. (Some caregivers may use a fetal stethoscope.) At the same time, he or she may place a hand on your abdomen to feel your contractions, then count your baby’s heartbeats, noting whether they speed up or slow down and recording the findings.


There are two types of EFM. The commonly used external EFM uses belts to place two sensors on your abdomen, and the rarely used internal EFM uses two sensors placed inside your uterus. (Caregivers use internal EFM only if external EFM isn’t picking up adequate signals.) One sensor picks up your baby’s heartbeat; the other picks up changes in your uterine tone or pressure (that is, your contractions). These sensors may be connected to video screens in your room or at the nurses’ station. The screen displays two graphs that indicate your baby’s heart rate and the intensity of your contractions. A printout of the data may also be produced. All data are stored electronically. Your caregiver checks the video screen or printout to assess your baby’s well-being and your contraction pattern.

Studies that compare auscultation and EFM (continuous or intermittent) report that each method has similar newborn outcomes. Most caregivers at hospitals, however, prefer EFM because it lets nurses monitor many women at the same time from the nurses’ station (an advantage when the nursing staff is overextended) and frees them from having to record a baby’s heart rate by hand. Plus, electronically storing the data saves paper.


Continuous EFM may limit your contact with your nurse and may keep you in bed. By comparison, auscultation may feel more personal because your nurse focuses on you—not a screen—to monitor you and your baby, and it may work better with your coping strategy because you’re not restrained from moving about by the EFM device.

Caregivers generally prefer to use continuous EFM for women with high-risk pregnancies. If you and your baby are healthy and low-risk, you shouldn’t have to be monitored continuously. Twenty minutes of EFM when you’re first admitted to the hospital, followed by fifteen minutes of EFM each hour, is an accepted protocol as long as your baby’s heart rate remains normal. Obstetrical associations in the United States and Canada also endorse the protocol of auscultation for one minute during and after a contraction every fifteen to thirty minutes in the first stage, and every five to fifteen minutes during the second stage.

During pregnancy, check whether your caregiver or hospital uses continuous EFM and under what circumstances. If continuous EFM is routine for all laboring women, check whether the hospital offers wireless (or telemetry) EFM, which allows staff to monitor you continuously while you’re out of bed, walking around, or even in the bathtub.

For more information on the different types and techniques of monitoring, visit our web site

Evaluating Your Amniotic Fluid

When your membranes rupture, the appearance of your amniotic fluid can indicate your baby’s condition. Normal fluid is clear and has a slightly fleshy odor. If your fluid has the strong odor of old fish, you may have an infection. If your fluid is green or dark, your baby has expelled meconium (first waste) from her bowels, which may indicate that she’s stressed. The presence of meconium in amniotic fluid isn’t uncommon; it occurs in 20 percent of all labors. If your fluid shows signs of meconium, your caregiver will observe your baby’s heart rate frequently to assess her well-being.

When researching your caregiver and birthplace during pregnancy, ask about the protocol for treating a newborn who has expelled meconium during labor. Many caregivers suction the baby’s nose, mouth, and trachea (windpipe) when the head is born and before the first breath. The belief is that suctioning prevents the baby from inhaling meconium, thereby preventing breathing problems or a rare type of pneumonia called meconium aspiration syndrome. Other caregivers choose not to suction a baby who’s vigorous at birth, instead letting her breathe immediately. Research hasn’t found that aggressive suctioning prevents meconium aspiration syndrome.5 Instead, suctioning seems to cause abrasions in the membranes of the baby’s nose and mouth.

Monitoring Your Baby’s Well-being with Fetal Scalp Stimulation and Other Tests

If FHR monitoring raises concerns, your caregiver may further assess your baby’s well-being by fetal scalp stimulation. This test is reliable, simple, inexpensive, and can be repeated easily. During a vaginal exam, your caregiver presses or scratches your baby’s scalp. If your baby’s heart rate speeds up, he’s likely fine. If his heart rate slows down, he might not be tolerating labor well.

Fetal scalp blood sampling is another test that may be used to monitor your baby’s condition. It involves taking blood from your baby’s scalp and analyzing it for changes in blood chemistry caused by a lack of oxygen. Although this test is helpful, it’s rarely used because it’s invasive to the baby, takes longer to analyze, and is uncomfortable for the mother.

Third Phase: Transition

As its name suggests, you transition from the first to the second stage of labor during this phase. Your cervix is reaching complete dilation, and your baby is beginning to descend into your birth canal. At this time, your contractions are longer (ninety seconds to two minutes) and closer together (two to three minutes apart). Although your labor is still technically in the first stage, your body shows some signs of the second stage. Your emotions and physical sensations are intense. You feel tired, restless, irritable, and totally consumed by your efforts to cope. You may lose your ritual (see page 207). Your body begins secreting high levels of adrenaline, which may lead to a “fight or flight” response (temporary fear, nausea, vomiting, agitation, hot flashes, chills, and trembling), but the hormone is beneficial because you become more alert and have renewed strength and energy just when you need to push out your baby.6

Involuntary spasms (precursors of bearing down) may stimulate your diaphragm, causing you to hiccup, grunt, or belch. You may find yourself holding your breath and straining or grunting during each contraction; this reaction is the urge to push. (See page 258 for more information.) Your back or thighs may ache. Increased pressure may cause your legs or even your whole body to tremble, and it may also cause heavy vaginal discharge of bloody mucus. Despite the intensity and pain of contractions during transition, you may doze between contractions, as though your body is conserving all energy for managing them.

Transition often lasts less than an hour (usually between five and twenty contractions).


During transition, you become focused only on your labor; nothing else matters. The intensity of your labor may frighten you. You may feel that transition will last forever and you can’t cope much longer. In this phase, the encouragement and support from your partner, doula, and caregivers are essential.


Your responses to transition (such as fear, nausea, trembling, despair, crying, dependence on others, and difficulty maintaining your ritual) are natural and unique to your labor. Your goal at this time isn’t necessarily to remain calm, still, and relaxed during contractions. Instead, your aim is to maintain a coping ritual, with the help of your partner or doula if necessary (see page 256). You may rhythmically sway from side to side, tap your fingers or feet, stroke your belly, or rock back and forth. Or you may want your partner to stroke you or murmur rhythmically in your ear. You may find that moaning during contractions helps release tension. Or you may remain still and quiet during your contractions. Between contractions, try to relax and rest, if only for a few seconds.

You might like your partner to hold you close, or you might not want to be touched. You may want your partner to provide only eye contact and verbal encouragement. You may find hot, damp towels on your lower abdomen soothing. If you’re sweating, your partner can fan you or wipe your face, neck, and chest with a cool, damp cloth. If you’re able to doze between contractions, your partner can help you focus and begin breathing rhythmically as soon as the next contraction begins so the intensity doesn’t overwhelm you.


If you recognize that you’re in transition, you can cope better with this phase. If you think your cervix is only 5 or 6 centimeters dilated, you may become discouraged and worry that you have hours of demanding contractions to go. However, when you and your partner recognize the signs of transition described on page 254, your progress can hearten you. You can see that the challenges of transition lead to the second stage of labor, when your mental state will improve as the birth of your baby draws closer.

Pain Medications during Transition

You can get through transition without pain medications, especially if you have the following: a desire for a non-medicated labor, knowledge of what to expect and how to cope in this phase, good support, and a labor that’s progressing normally. Some women, however, find that transition is too much for them to handle; the pain is too great, they’re exhausted, or they lose control or panic. If this happens to you, pain medications are usually an option. (See Chapter 10.)

While there’s no shame in wanting medical help during this phase, don’t take pain medications just because you fear that the intensity of your labor is abnormal. Remember that strong emotional responses and challenging contractions are completely normal in transition. Before deciding on pain medications, first find out how far your labor has progressed. Because transition typically lasts less than an hour (ten to twenty contractions), you may decide that pain medications are unnecessary.

Urge to Push in Transition

In this phase you may develop an urge to push, which may feel as though you need to have a bowel movement (because your baby’s head is pressing against your rectum). You may also start catching your breath and grunting (that is, making “pushing sounds”). When you first feel an urge to push, let your nurse or caregiver know. Try not to push until he or she can assess you. If your cervix isn’t completely dilated or is almost dilated except for one thickened area (a “lip” of cervix), you may be asked not to push.

In Their Own Words

It’s hard to watch your girlfriend be in pain and know there’s nothing you can do. I just stayed strong for her and let her know I wouldn’t leave her side. Observing the confidence in the staff and seeing my girlfriend smile when our son was born let me know that everything was fine.


While it’s usually okay to bear down in labor, doing so isn’t worthwhile before your cervix is fully dilated. In fact, pushing too early may cause your cervix to swell and slow your labor progress. You may find it difficult and uncomfortable to keep from pushing when the urge is strong. If you’re asked not to push, try blowing or panting to keep from holding your breath. (See page 228.) You may be able to relieve a premature urge to push by changing positions, such as to the hands-and-knees, side-lying, or other positions that neutralize the effects of gravity. See page 258 for more information on the urge to push.

A Note to Fathers and Partners

Transition is probably the most difficult challenge that you’ll ever see your laboring partner experience. Her pain and discouragement may trouble you, but remember that her intense sensations and emotions are normal. She and your baby are all right. Nonetheless, you both need reassurance and encouragement from your doula, nurse, or caregiver at this time. See Appendix B for suggestions on ways to help your partner throughout labor.

Your job during this phase is simple: Help her keep a rhythm (see page 206). Listen closely for whatever rhythm she may have and help her maintain it. It’s very likely she may need you to give her a rhythm to follow. (See the Take Charge Routine below.) Don’t mistake rhythmic moans, groans, or other intense sounds for cries of agony. If they’re rhythmic, she’s coping.

If she begins catching her breath and grunting (making pushing sounds), she may have an urge to push. Call her nurse or caregiver. She may be in the second stage of labor and ready to push!

Take Charge Routine for Partners

Use this routine when your laboring partner is in despair, weeping, crying out for help, or ready to give up. Also use this technique when she’s overwhelmed with pain, can’t relax, and can’t regain her coping rhythm or ritual.

• Keep your composure. Your touch should be firm and confident. Your voice should be calm and reassuring. Give simple, concise directions. Don’t ask her questions.

• Stay close to her. Remain by her side with your face near hers.

• Anchor her. Hold her hand or cradle her in your arms.

• Make eye contact. Tell her to open her eyes and look at you or at your hand. This helps her focus.

• Give her a rhythm to follow with her breathing; move your hand or head to set a pace for her to follow (about one breath per each second or two). If she loses the rhythm, say, “Breathe with me; follow my hand. That’s the way, just like that.” Nod your head in time with her breathing to reinforce the rhythm.

• Encourage her. Acknowledge that labor is difficult, but not impossible. Remind her that she’s made a lot of progress and that her baby will be here soon. Tell her to look at you the moment she feels the next contraction so you can help her. Immediately set a rhythm for her to follow.

• Repeat yourself. She might not be able to do what you tell her for more than a few seconds, but repeating your instructions will help her continue.

Short, Fast Labor

Occasionally, a woman’s entire labor lasts only six hours or less and leads to a precipitate birth. In this type of labor, contractions may have started only three or four minutes apart, lasted a minute each, and were already so intense that the woman couldn’t cope with them. A labor this fast is rare among first-time mothers, but a few may have labors that are as short as three hours. Short, fast labors are much more common for women who have given birth before. If your labor progresses quickly and a precipitate birth is imminent, forget the 4-1-1 or 5-1-1 rule (see page 244)—call your caregiver!

Although a quick labor may sound appealing, it presents its own challenges. Early labor may pass unnoticed or so quickly that you suddenly find yourself in active labor without time to prepare psychologically. Your first noticeable contractions may be long and painful. You may feel confused, unprepared, and even panicky, especially if you think what you’re experiencing is prelabor or early labor. You may quickly lose faith in your ability to handle the rest of labor.

If you’ve planned a hospital birth, you may hurry to the hospital, all the while trying to cope with strong, almost continuous contractions. At the hospital, you’re probably met by unfamiliar caregivers, who spark a flurry of activity. You may feel anxious and alone if your partner is unable to accompany you. Even if he or she is with you, you may want to give up and take any medication available to you to make the pain disappear or at least become manageable. Your partner is probably caught off guard and shocked by the sudden intensity of your labor, especially if he or she also believes you’re experiencing early labor.

What You Can Do If Your Labor Is Rapid

If it’s clear that your baby will be born quickly, don’t give up on your ability to cope. Try not to tense up during contractions and use slow breathing (see page 224). If slow breathing doesn’t help you, use light breathing (see page 225). Moan or bellow rhythmically, if doing so is helpful. Consent to a vaginal exam before making any decision about pain medication; your cervix may have already dilated to 8 or 10 centimeters. If your labor has progressed this rapidly, anesthesia may be unnecessary or may take effect too late to provide relief before your baby’s birth. Rely on your partner, doula, and staff to help you cope with contractions and to reassure you that you and your baby are doing well.

In a rapid labor, contractions are intense and effective, and you may have the urge to push before staff is ready. If this happens in your labor, lie on your side and pant or gently bear down. Doing so gives your birth canal and perineum more time to stretch, decreasing the likelihood of vaginal tearing.

After the birth, you’ll probably be relieved that you and your baby are safe, but stunned that the entire event passed so quickly. You may also feel disappointment because you weren’t able to fully appreciate the experience, to use all the breathing and relaxation techniques you learned, or to share the birth with your partner as you’d planned. You may need to discuss the sequence of events with your caregiver and partner so you can process the birth and come to terms with it.

Although less than 1 in 1,000 babies are born on the way to the hospital or birth center,7 in the unlikely event that you start to give birth before you leave home or en route to the birthplace, or before your home birth midwife arrives, you and your partner should know how to safely catch your baby. See page 300 for more information on rapid birth without medical help.

Second Stage of Labor: Birth of Your Baby

As soon as your cervix has dilated completely, you’re in the second stage of labor. A new sequence of events begins: Your baby gradually leaves your uterus, rotates within your pelvis, descends through your vagina, and is born.

The second stage typically lasts between fifteen minutes to more than three hours. For a first-time mother, the average time for this stage is ninety minutes to two hours. For a mother who has given birth before, the second stage is usually faster than it was for her first birth.


During the second stage, the pain of your contractions lessens and the interval between them increases. You calm down and can think clearly again. You experience renewed energy and become optimistic and aware of those around you. Now you can collect yourself for pushing your baby out.

Urge to Push

The urge to push is the most significant sign of the second stage. It’s a combination of forceful sensations and reflex (involuntary) actions caused by the pressure of your baby in your vagina during contractions around the time your cervix is fully dilated. The urge to push occurs several times within a contraction and indicates that your uterine muscles are pushing your baby downward. When you have the urge to push, you experience a compelling need to grunt or hold your breath and bear down. It may feel like a strong urge to have a bowel movement.

Whether you have an urge to push immediately at this time or after a brief rest depends on the degree and speed of your baby’s descent, her station and position within your pelvis, your body position, and other factors. Ask your caregiver to check the dilation of your cervix. If it’s fully dilated, you generally can begin pushing when you feel the urge. If it’s not fully dilated but is very ripe and effaced, you may be asked to bear down only enough to satisfy the urge. If your cervix isn’t completely dilated, you may be asked not to push (see page 228). Because the urge to push is involuntary, resisting it may postpone pushing, but only temporarily.

For many women, responding to the urge to push is one of the most satisfying aspects of the birth experience; some women even orgasm when giving birth. Others find pushing painful and exhausting, while many are simply relieved to be able to start pushing.

Note: Some women don’t feel a strong (or any) urge to push in this stage. Usually, time or changing to an upright position can strengthen the urge to push. Also, if you receive pain medication, especially epidural anesthesia, you might not feel the urge to push or it might be a vague sensation.


During the second stage, the following three key concepts should guide you and your caregiver: Don’t rush. Push when you have an urge. Use different positions.

Don’t Rush

Although you and your caregiver are anxious to have your baby born, it’s best not to rush the birth. Bear down or push spontaneously as the urge demands and allow time for your vagina to stretch open gradually, which decreases the likelihood of vaginal bruising or tearing.8 Don’t use prolonged pushing (see page 258). You also use your energy more efficiently if you don’t rush. By holding your breath and bearing down only when you can’t resist the urge, you’re working with your uterus and not wasting effort.

Push When You Have the Urge

The following are descriptions of the different ways to push under certain circumstances in labor.

Expulsion breathing and spontaneous bearing down

Use when you have an urge to push (see page 258). With spontaneous bearing down, you naturally bear down or strain for five to six seconds at a time and take several breaths between efforts. This type of pushing makes more oxygen available to your baby than if you hold your breath and bear down for as long as possible.9 Spontaneous bearing down also allows your vagina to stretch gradually, reducing your risk of tearing.

Delayed pushing (passive descent or laboring down with an epidural)

When you have an epidural, you probably don’t have an urge to push until your baby is close to being born. Your uterus continues pushing your baby down and into a good position, but you don’t feel the need to push in response.

With delayed pushing, try to rest and refrain from pushing until your baby’s head can be seen at your vaginal opening (crowning) or until you feel the urge to push. This way, if your baby is occiput posterior (see page 285) or his head is tilted (either a likely occurrence if you have an epidural), you avoid forcing him too deeply into your pelvis before he can reposition himself. Delayed pushing usually means a longer second stage, but as long as your baby is doing well, research shows that waiting an hour or two before pushing with an epidural gives your baby time to gradually reposition until his head is visible.10Delayed pushing is also much less tiring for you. It greatly improves your chances of a spontaneous vaginal birth (one that doesn’t require vacuum extraction or forceps delivery) and greatly decreases your chances of needing a cesarean.

When it’s time to push, your nurse or caregiver will probably tell you when and how long to push during each contraction.

Directed pushing

Directed pushing is used if you can’t feel your contractions and delayed pushing isn’t an option or if spontaneous pushing isn’t effective. Your caregiver will tell you when, how long, and how hard to push. (See page 233 for more information on directed pushing.)

Prolonged pushing

Prolonged pushing differs from directed pushing in the length of time you’re expected to hold your breath and bear down (ten seconds or more, instead of five to seven seconds).

Not long ago, standard practice in maternity care required that women push for as long and as hard as they could, in order to push out the baby as quickly as possible. Many maternity caregivers are still more comfortable advocating prolonged pushing than spontaneous bearing down. Research shows, however, that prolonged, forceful pushing usually isn’t necessary and may sometimes cause problems that are less likely to occur with spontaneous bearing down, including exhaustion of the mother, overstretching of pelvic ligaments and muscles, possible perineal tears, later urinary incontinence (leaking of urine), concerns with the baby’s heart rate, and failure of the baby to rotate or descend.11

Prolonged pushing, especially in the supine position (on your back), can also decrease the oxygen available to your baby and may cause your blood pressure to drop, both of which can increase the need for a faster delivery with an episiotomy. The second stage may last slightly longer with spontaneous or directed pushing than with prolonged pushing, but babies usually remain in good condition throughout the process.12

Prolonged pushing is best reserved for women with inadequate progress in the second stage, even after trying different positions, or for women whose babies are already in distress and may require interventions (such as a forceps delivery, vacuum extraction, or cesarean birth) unless they’re pushed out quickly. Well before your due date, discuss prolonged pushing with your caregiver. Include your preferences regarding the practice in your birth plan and discuss them with the staff when you arrive at the hospital or birth center. See pages 232–234 for more discussion on the various pushing techniques.

Use Different Positions

As long as your labor is progressing well in the second stage and your baby is fine, use whatever positions seem most comfortable to you. If your caregiver is concerned about your progress or your baby’s well-being, he or she may recommend that you try a different position. Even if it’s uncomfortable, this new position may correct the problem and avoid the need for further interventions.

If your second stage is rapid, try a position that neutralizes the effects of gravity, such as side-lying, to help slow down labor. If progress is prolonged, try positions that take advantage of gravity. Be prepared and willing to change positions every twenty to thirty minutes. (See pages 222–223 for descriptions of positions.)


Some caregivers are comfortable with having a woman give birth in any position she desires. However, most caregivers prefer a position that they’re used to (usually semi-sitting or on the back),13 which might not be the best position for comfort or progress. During pregnancy, discuss your options with your caregiver. If he or she delivers babies in only one position, plan to use several other positions throughout early second stage to aid labor progress. During second stage, if pushing is prolonged, ask whether a change in position might help resolve the situation.

Note: If you’ve received pain medications, your mobility and choice of positions may be limited. (See Chapter 10.)


The second stage has three phases: the resting phase, descent phase, and crowning and birth phase. These three phases share characteristics with the three phases of the first stage. High spirits, little pain, and slow progress characterize the first phases of both stages. Intense contractions, total mental absorption, and steady progress characterize the second phases. Lastly, intense sensations and confusion characterize the third phases.


Resting Phase

After the intensity of transition, your uterus may stop contracting for ten to twenty minutes, allowing you to rest, clear your head, recoup your energy, and grow excited for your baby’s imminent arrival. This resting phase is normal and may occur because your baby’s head has slipped into your birth canal, causing your uterus, which had been stretched tightly around your baby, to slacken. Your uterus needs a few minutes to adjust to the change, but once it begins to tighten around the rest of your baby’s body, strong contractions resume and your urge to push becomes powerful.

The resting phase doesn’t occur in all labors. If your baby is low in your pelvis when the second stage begins, or if she’s descending rapidly, your body may skip this resting phase or make it brief. Even if this phase doesn’t offer you much rest, you probably still become clearheaded and emotionally recharged as you move into the second stage.

If the resting phase lasts longer than fifteen to twenty minutes, your caregiver may ask you to try a position that enhances the effects of gravity to encourage an urge to push. Or he or she may direct your pushing, asking you to hold your breath and bear down even if you don’t have an urge to push. Directed pushing may frustrate both you and your caregiver, as labor progress rarely occurs without the urge to push. However, directed pushing may be worth trying before using a medical intervention such as Pitocin (see page 281).

In Their Own Words

When I was dilated, my midwife told me I was ready to push—but I didn’t feel ready! She had me try the squat bar and sitting on the toilet, which just made the pain more intense and didn’t give me an urge to push. I remembered reading that there’s sometimes a lull between transition and pushing, so I wasn’t worried. I asked my doula and my husband to tell the staff that I wanted to push spontaneously when I was ready. My wishes were respected and I slept between contractions until I finally began bearing down.


Descent Phase

During this phase, your baby descends into your birth canal and likely completes rotation to the occiput anterior position (see page 285). At this time, powerful contractions make your urge to push irresistible. You may find bearing down thrilling and rewarding because you can feel progress. Or you may feel alarmed by the full, bulging, stretching feeling in your perineum. You may tense your pelvic floor and “hold back” (see page 262), afraid to let your baby descend. When pushing, it’s important to relax your pelvic floor and bulge your perineum (see page 96). Prenatal perineal massage (see page 235) is excellent preparation for the second stage because it teaches you to relax your perineum while it’s being stretched. Your partner can help you during this phase by reminding you to relax, open up, bulge your bottom, or ease your baby out. This type of encouragement is usually more helpful than being told to push, push, push!

In this phase, you may need several contractions before you can push effectively. If you have trouble figuring out where to direct your efforts when pushing, ask your caregiver to perform perineal massage or to use a warm compress to give you a location. Using a mirror to watch what happens when you push may also help you figure out how to push more effectively.

Clenching your jaw and clamping your lips together are signs that you’re also tensing the muscles in your vagina. By relaxing your face and mouth, you may be able to relax your vagina.

Holding Back during the Descent Phase

During the second stage, you may tense your pelvic floor (at least briefly) in response to the stretching sensations you feel when your baby’s head is in your birth canal. Holding back is normal and usually passes quickly once you feel your baby descending.

To stop yourself from holding back, try telling yourself to let go. If successful, the pain decreases and you won’t have a desire to hold back again. However, you may have trouble letting go for one or more of the following reasons:

The pressure of your baby’s head within your vagina alarms you, and you find it difficult to give in to that pressure.

Remind yourself that holding back tends to increase pain and slow progress. You’ll feel so much better after letting go! Listen to your partner, doula, and caregiver when they encourage you to let go and let your baby out.

Try sitting on the toilet for a few contractions. This position may help your perineal muscles release naturally because it’s associated with “letting go” of urine or a bowel movement.

Warm compresses on your perineum can help because the moist heat promotes relaxation and relieves the stretching sensation. This simple, inexpensive comfort measure also alleviates perineal pain and reduces the risks of tearing and urinary incontinence (see page 352).14 In addition, having your caregiver press the cloth on your perineum reassures you that he or she will help guide your baby out. Before your due date, discuss using warm compresses during labor with your caregiver and include the option in your birth plan (see Chapter 8).

Note: During this phase, some caregivers use their fingers to stretch a woman’s perineum. While this practice may help her push more effectively, research finds that it’s often very painful and is no more effective for enlarging the vaginal outlet and preventing a tear than the use of warm compresses or even no treatment.15

You’re uncomfortable with having people stare at your perineum.

Try to recognize that they’re watching the progress of your baby, but ask to be covered as much as possible. For example, warm compresses can conceal your perineum as they help relax and stretch it.

You fear you’ll have a bowel movement while pushing.

Because your baby presses on your rectum while descending, it’s normal to pass a small amount of stool when you push. When this happens, your nurse or caregiver interprets it as labor progress. You might not even be aware of it, because your caregiver wipes away and removes the stool discreetly (perhaps with a warm compress, if one is used to help your perineum relax and stretch). Sitting on the toilet for a few contractions may help you dispel this fear and relax.

If you’ve been sexually abused, you fear that the sensations of your baby in your vagina will remind you of your abuse.

It may help to tell yourself that you’re pushing your pain out of your body as you push out your baby. Because it’s important to separate your abuse from the birth of your child, see page 59 for more information on sexual abuse and childbearing.

If you let yourself release tension and push despite the pain, you’ll find that pushing feels better than holding back.

As this phase progresses, the joy and anticipation you feel give you renewed strength. Your perineum begins to bulge, your labia part, and your vagina opens as your baby’s head descends each time you bear down. Between pushes, your vagina partially closes and your baby’s head retreats. With another contraction, your baby moves farther down, his head becomes clearly visible, and you may be able to see it in a mirror. You may want to reach down and touch his soft, wrinkled head. The normal squeezing of your baby’s head by your vagina causes the scalp to wrinkle until his head moves farther down your birth canal.

Crowning and Birth Phase


The third phase of the second stage is the crowning of your baby’s head and her birth. It begins when your baby’s head no longer retreats from your vaginal opening between pushes, and it ends when her body completely exits yours. During this phase, your vaginal opening stretches to its maximum, which likely causes a stinging, burning sensation called the “rim of fire.” To reduce the risk of a vaginal tear or a rapid birth, you may need to stop pushing to let your vagina and perineum gradually stretch around your baby’s head as it emerges. Depending on the speed of the birth, your caregiver may direct you to push only moderately or to push only between contractions. He or she may ask you not to push at all (see page 228 to learn how to resist the urge to push). Your caregiver may support your perineum with warm compresses to prevent your baby’s head from coming too rapidly and to help your perineum stretch gradually.

Research finds clear problems with routine episiotomy to enlarge the vaginal opening; nonetheless, some caregivers still commonly perform episiotomies. See pages 289–290 for more information on episiotomy.

Two Views on Crowning and the Birth

When Grace finally crowned, I knew my wife could push her out, even though she was starting to feel exhausted. Sure enough, she tapped into a source of strength that probably surprised her as much as it did me, and pushed our daughter out. Grace was so slimy! But she was also so gorgeous, I cried when I saw her.


When I began pushing, Jacob was holding my left hand and the nurse was murmuring instructions in my right ear. I didn’t feel that my contractions were coming close enough together. I could feel a burning sensation as my baby’s head slowly moved down. Everything seemed in slow motion. Finally, with a rush of pain and a huge relief, my daughter came out.



Protecting Your Perineum from a Large Tear or an Episiotomy

Many women worry that pushing will damage their vaginal tissues, or they fear that an episiotomy will be needed. Here are research-based actions you can take during pregnancy and labor to protect your perineum:

• Choose a caregiver who prefers to avoid episiotomies and has a low rate of doing the procedure (less than 20 percent).

• Good nutrition promotes healthy tissues, so eat well during pregnancy.

• Perform perineal massage regularly for a few weeks before the birth. (See page 235.)

• When you push, use spontaneous bearing down or bear down for only five to seven seconds each time.

• During the birth, use positions that put minimal strain on your perineum, such as side-lying, kneeling, or hands-and-knees. (See page 222.)

• Also during the birth, pant lightly and listen to your caregiver’s directions to avoid pushing while your baby’s head and shoulders are born.

Your Baby’s Birth

The second stage of labor ends with your baby’s birth. If your baby’s position is head down (occiput anterior or posterior), first the crown of his head emerges, followed by his brow and face. His head appears bluish-gray and is soaking wet. After his head is out, it rotates to the side to allow his shoulders to slip more easily through your pelvis. One shoulder emerges, followed by the rest of his body, perhaps rather quickly. You or your partner may want to help catch your baby.

Your baby’s body may appear bluish at first and may be streaked with blood, mucus, and vernix caseosa (a white, creamy substance that protected your baby’s skin in your womb). With your baby’s first breath, his skin color quickly becomes normal. All babies, regardless of skin color, experience this change in the first minutes of life, as respiration and circulation become stable. See Chapter 17 for more information on your newborn’s appearance.

Your caregiver’s or birthplace’s policy may require that your baby have his nose and mouth suctioned immediately after the birth. However, studies find that healthy vigorous newborns don’t benefit from this procedure.16 During pregnancy, discuss your caregiver’s or birthplace’s policy on suctioning and include your preferences in your birth plan (see Chapter 8).

While you await the delivery of the placenta, your baby may be dried and immediately placed on your abdomen or in your arms. The umbilical cord is typically clamped and cut around this time; however, there are long-term advantages for your baby if cord clamping is delayed. (See page 267.) The custom in some hospitals is to assess a newborn’s well-being while he’s in a baby warmer in the birthing room. However, research shows that newborns are warmer and begin breastfeeding earlier when kept skin-to-skin with their mothers; in addition, most women report greater satisfaction when they have their babies with them immediately after the birth than if they’re separated from them. Before the birth, find out your hospital’s custom on the use of baby warmers; in your birth plan, express your preference to hold your baby immediately after the birth (if he’s doing well). Your nurse or caregiver can assess your baby while he’s in your arms or at a later time, after he’s had at least an hour of skin-to-skin contact with you.


After your baby is born, your first response may be, “It’s over! No more contractions!” and you may feel grateful and relieved that your baby is finally out of your body. These feelings may initially overtake your interest in your baby, especially if you had a long, tiring labor.

Conversely, you may temporarily forget about your labor and birth the moment you see or hear your newborn. You may be surprised or awed by your baby’s appearance. You may hold your breath in suspense until you hear her begin to breathe, smiling with relief and joy when you hear her first hearty cry. If your caregiver needs to inspect your perineum and check for separation of the placenta, you may find the procedures painful and distracting, and you may be unable to focus completely on your baby. After your caregiver has finished these tasks, however, you can return your total attention to your baby.

In Their Own Words

After my baby was placed on my chest, my body began shaking uncontrollably. The lights were turned back on, and I opened my eyes to stare at this slimy, squirmy thing that had been living inside of me. I always thought I’d need medication, but everything went so fast that I had a natural birth. It was an amazing, scary, and wonderful experience—something I will never forget.

—Mary Ann


The birth of your baby requires great physical effort by your laboring partner, even if she has an epidural. Here are ways you can assist her during this stage:

• Help her change positions and physically support her as needed.

• Encourage her to relax her pelvic floor as she pushes.

• Cheer her on as she pushes, but be sure you don’t override her caregiver’s directions.

When your baby is born, you may experience happiness, exhaustion, relief, wonder, joy, and love for your partner and your baby—all at the same time. Your baby becomes the focus of your attention.

If your baby can’t remain in your partner’s arms immediately after the birth (probably because of concerns for his well-being or because the staff want to check him carefully in a baby warmer in the room), stay with him so you can report what you see being done to him to your partner. Talk to your baby; he knows your voice and hearing it calms him.


Third Stage of Labor: Delivery of the Placenta

Typically lasting between ten and thirty minutes, the third stage is shorter and less painful than the earlier stages. It begins with the birth of your baby and ends when the placenta is delivered. The following sections describe what you can expect during this stage and discuss the care your newborn will likely receive immediately after the birth.


After your baby is born, contractions stop briefly, then resume with the purpose of separating the placenta from your uterine wall. Although these contractions are typically much less intense than those before your baby’s birth, you still may need to use relaxation techniques and rhythmic breathing. Or you may be so engrossed in your baby that you hardly notice these contractions. Your caregiver will probably direct you to give a few small pushes to deliver the placenta. You may appreciate seeing the placenta after it’s delivered; after all, it’s an amazing organ that allowed your baby to thrive in your womb.


Within one minute after the birth and again at five minutes, your caregiver evaluates your baby’s well-being by conducting a routine newborn assessment called the Apgar score. As soon as your baby is breathing and dried off, your caregiver considers five factors and give a score of zero to two points for each one (see below). A score of seven to ten indicates that your baby is in good condition. A score of six or less means your baby needs additional medical attention and observation.

The Apgar score can be done while you hold your baby. Babies seldom receive a ten on the first score (most babies’ hands and feet are bluish for a while after the birth). If your baby’s first score is six or less, your caregiver may have her taken to a baby warmer in the birthing room for stimulation or possibly oxygen. The second score is usually higher than the first score, indicating improvement with time or medical assistance.

While Apgar scores help detect babies who need immediate medical attention, they can’t predict a baby’s overall health or long-term well-being. Your nurse or caregiver performs a thorough newborn exam (within twenty-four hours of the birth) to more accurately assess your baby’s condition.

Apgar Score


0 points

1 point

2 points

Heart rate


Fewer than 100 beats per minute

More than 100 beats per minute

Respiratory effort


Slow, irregular

Good, crying

Muscle tone


Arms and legs flexed

Active movement

Reflex irritability (your baby’s reaction to something placed in her nose)

No response


Sneezing, coughing, pulling away

Skin color

Bluish-gray, pale all over

Normal skin color, except for bluish hands and feet

Normal skin color all over


Soon after birth, your baby’s umbilical cord is clamped, then cut with scissors. Your partner may cut the cord.

The timing of cord clamping and cutting affects your baby’s blood volume. Before birth, your baby’s blood circulates via the cord to and from the placenta, allowing the exchange of oxygen, nutrients, and other substances. At birth, one-third or more of your baby’s blood is in the placenta,17 but over the first few minutes, it transfers to your baby. The blood vessels in the cord are gradually compressed by a substance called Wharton’s jelly, which expands when the cord is exposed to air. If the cord is clamped immediately, which is still a common practice, your baby doesn’t receive a large portion of his blood from the placenta. Delaying clamping until the cord stops pulsating allows your baby to receive as much blood as possible. Some blood remains in the placenta after pulsation stops.


For years, obstetricians and others had been taught that placental blood is “extra” and that if it got to the baby, it could lead to jaundice (see page 389). But this belief has been disproved.18 In fact, delayed clamping benefits the baby by helping increase blood levels of iron and reduce anemia at ages two months and six months. It may also hasten separation and delivery of the placenta by decreasing its size.19

To achieve the optimal blood volume, the baby is placed on the mother’s abdomen (level with the placenta) until the cord stops pulsating. Then it is clamped and cut. Holding the baby high above or low below the mother may alter the speed of transfer of blood that passes between the placenta and baby,20 but placement on the mother’s abdomen is the most physiologic and seems appropriate under most circumstances.

In challenging situations, the baby may benefit even more from delayed cord clamping. Some hospitals are waiting a few minutes to clamp and cut the cord after a cesarean.21 For a baby who needs medical attention or resuscitation, these procedures can often be carried out with the cord intact so the baby, while remaining next to his mother, continues to benefit from oxygenated blood transferring to him.

During pregnancy, discuss delayed cord clamping and cutting with your caregiver and include your preferences in your birth plan.


Blood in the umbilical cord is a rich source of stem cells, which generate and continually renew supplies of red cells, platelets, and white cells. Stem cells make it possible for a person to use oxygen, clot blood, and fight infection. Stem cells found in umbilical cord blood are easier to match to another person’s tissue than are the more mature stem cells found in bone marrow. As a result, cord blood stem cells can be used to successfully treat people with such diseases as immune deficiencies, severe inherited anemia, and childhood leukemia and other cancers. Stem cells are also used in the search for cures of these diseases.

The value of cord blood in treating diseases has led many expectant parents to consider having their babies’ cord blood collected and stored. Cord blood collection is done after the baby’s cord is cut, and it’s accomplished most successfully within ten minutes after the birth,19 which means that the baby still benefits from delayed cord cutting (see above). After collection, the stem cells are then separated from the blood in a laboratory and stored either in a blood bank for use by the public or in a private storage facility for later use, if needed, by the child or her family.

The American Academy of Pediatrics (AAP) encourages parents to donate cord blood to public blood banks and cautions against using private cord blood banks.22 The reason is because most conditions that cord blood stem cells may help treat (such as precancerous changes and genetic abnormalities) already exist in the baby’s cord blood, which means that her stored cord blood stem cells won’t help treat the condition if she develops it later. (The AAP also points out that private cord blood storage is often expensive.) Publicly donated cord blood is tested for disease and genetic abnormalities before being approved for use.

If you’re interested in learning more about cord blood collection, donation, or storage, ask your caregiver, contact your local blood bank, or search the Internet for unbiased sources of information. Do this research well before your due date.


Fourth Stage of Labor: Recovery

The fourth stage of labor begins just after the placenta is delivered and lasts until your condition is stable, typically an hour or two after the birth. This stage may last longer if you had anesthesia, if your labor was difficult or prolonged, or if you had a cesarean birth.

After you deliver the placenta, your caregiver checks your perineum and birth canal for bleeding. If you had a vaginal tear or an episiotomy during the birth, your tissues are stitched to speed healing, a procedure that typically lasts less than thirty minutes. Unless you were already given anesthesia in labor, you receive a local anesthetic by injection before your perineum is stitched. Although the stitching should be painless, the injection may sting and you may need to use rhythmic breathing to manage the discomfort.

If your perineum is intact or you have a shallow tear, you don’t need stitches, but the area may become swollen or bruised. Whether you have stitches or not, you’ll appreciate having an ice pack placed on your perineum to reduce any swelling and relieve discomfort.

After the birth, your uterus begins the process of involution (returning to its nonpregnant size). It continues to contract, and by doing so, closes the blood vessels where your placenta was implanted in order to prevent excessive blood loss and to prompt the shedding of the uterine lining that built up during pregnancy. You quickly begin passing lochia, the heavy red discharge made of the extra blood and fluid that supported your pregnancy and the uterine lining that sustained your baby. A maternity pad is necessary to absorb the flow.

Once the placenta is delivered, your nurse or caregiver checks your uterus frequently to make sure that it remains firm. If your uterus is relaxed, he or she massages it firmly, causing it to contract and preventing excessive blood loss. Uterine (or fundal) massage can be painful, and you may want to do it yourself to control the amount of pressure used and perhaps reduce pain to a tolerable level. See page 270 to learn how to do uterine massage or ask your nurse for instructions.


Your contractions during involution may be painful, especially if you’ve given birth before. Although these afterpains are common and aren’t nearly as intense as labor contractions, you may need to use slow breathing to help manage them.

After your baby’s birth, your legs may tremble for a while, which is normal. A warm blanket may reduce the trembling. You may also realize that you missed some meals during the hard work of labor. Be sure to eat and drink to satisfy your hunger and quench your thirst.

This stage gives you a chance to get to know your baby without disturbances and to let him nuzzle at your breast. Most babies are ready to suckle within twenty to sixty minutes after the birth. See page 405 to learn more information about your baby’s first feeding.

How to Massage Your Uterus

1. Empty your bladder. Lie on your back and check your uterus by pressing on the area below your navel. If your uterus feels as firm as a grapefruit, you don’t need to massage it. If you can’t feel your uterus, it has relaxed and softened. Proceed to the next step.

2. With one hand slightly cupped, massage your lower abdomen firmly with small circular movements until you feel your uterus contract and become firm. This action may be painful (but probably less so than if someone else does it). If you can’t make your uterus contract, tell your nurse or caregiver. He or she will massage your uterus to make it contract.

Because your uterus can bleed excessively if it’s not firm, don’t skip this massage on the first couple days after the birth. Afterward, you may periodically check to see if your uterus needs massage to keep it contracted. See page 354 to learn what’s done if your uterus doesn’t contract or you have excessive bleeding.


After the birth, your baby’s stress hormones (catecholamines) stimulate her adaptation to life outside your uterus. These hormones absorb fluid in her lungs so she can breathe easily, jump-start her ability to regulate her temperature, and make her alert and heighten her reflexes for the first few hours, during which time she begins feeding, exploring her world, and seeing you for the first time.

During labor, your baby produced beta-endorphins; after the birth, she produces prolactin. She also begins producing oxytocin (the “love hormone”) in synchrony with you. These three hormones help strengthen the bond between the two of you, increase her interest in breastfeeding, and stimulate you to care for her. Other people also can produce oxytocin—although to lesser degrees than what you produce—by holding your baby skin-to-skin, keeping eye contact with her, and caring for her.

By snuggling with your baby after the birth, the skin-to-skin contact allows for mutual regulation of hormones as you adjust to your new lives together.


A main characteristic of the fourth stage is that you and your partner are no longer expectant parents—you’re parents! After the birth of your baby, you don’t get a chance to regroup before you begin parenting your child. This new role, along with other postpartum changes to your life, may overwhelm or bewilder you. In Chapters 1517, and 18, you’ll learn about feeding and caring for your baby as well as your emotional and physical adjustment after his birth.

Enjoy your baby’s first hours of awake time. He’s likely alert, calm, and bright-eyed, as he begins observing and sensing new sounds, smells, sights, touches, and tastes. If the light isn’t too bright, he’ll stare, particularly at your face. (If the light is too bright, ask someone to dim them or use your hand to shield your baby’s eyes.) As your baby cuddles with you, gazes into your face, or suckles at your breast, your curiosity will give way to fascination. These moments are a time for falling in love with each other. Your partner also will want to hold your baby close, perhaps skin-to-skin, and bond with him.

Family-centered and Baby-Friendly hospitals (see page 12) encourage parents and babies to stay together as much as possible after the birth, unless problems develop that require separation. At these hospitals, the caregiver performs routine observations or procedures on a healthy, normal baby while the newborn is in his mother’s or other parent’s arms. Before your due date, check your hospital’s policy on newborn procedures. If caregivers routinely send healthy newborns to the nursery, ask your caregiver to issue an order to delay or bypass your baby’s admission to the nursery. See Chapter 17 for more information on newborn care.

A few hours after the birth, your baby will probably fall deeply asleep. You and your partner may do the same, as exhilaration gives way to fatigue. At that time, someone who’s alert should periodically observe your baby’s vital signs and yours, including skin color, pulse, respiration, blood pressure, and temperature. Your partner may be as exhausted as you and unable to take on this responsibility until after he or she rests. In the hospital, a nurse does this job. After a home birth, the midwife or a birth assistant makes initial observations before passing the job on to an informed and rested friend or relative.


Your birth experience isn’t really over until you’ve had a chance to think about and understand it. Giving birth to your child will become one of the most vivid and poignant memories you’ll ever have. In order to create a complete story of the experience, you need to compare and contrast your feelings, thoughts, and impressions with those of others who attended the birth, getting answers to any questions, and looking at photos taken during labor and birth. At some point, you may want to tell your story to people who didn’t attend the birth but are eager to hear about it. You may even want to write the story or draw or paint a picture of it—each option is a great way to preserve this special memory for you and your child.

Depending on your birth experience, processing it may take weeks, months, or even years. If your birth experience was particularly difficult or disappointing, processing it may take longer than processing an easy and satisfying experience. Dealing with a difficult birth may also bring up strong, disturbing feelings. If this is the case for you, talk about your experience with your caregiver, doula, childbirth educator, or a counselor knowledgeable about childbirth. This person can help you gain perspective and come to terms with your birth experience. See page 352 for further discussion on troublesome or disappointing birth experiences.

Key Points to Remember

• By understanding what happens in each stage of labor, you can anticipate and appreciate the physical accomplishments of each stage, respond well to the accompanying emotional hurdles, and cope with increasingly intense contractions.

• Expect the unexpected in labor. Know that there are steps you can take to respond to any variation in labor, from a rapid labor to a prolonged one.

• Your labor partner’s presence and support are vital to your ability to cope with labor.

• Your baby also labors. The two of you labor together and adjust together to your new roles afterward.

• See Appendix B for a quick reference chart that summarizes the stages of labor and briefly explains what you can do during each stage to help labor progress and increase your comfort.