There are three stages of labour - the way they all start and progress, will differ for every woman.
During the first stage of labour, your cervix thins and dilates to around 4cm dilation (opening). The second stage involves powerful contractions that further dilate your cervix and ends in the birth of your baby. The third stage of labour is delivery of the placenta: the incredible temporary organ that you made to support your baby as it grew. Understanding the stages of labour will help you to prepare for what’s to come; whether this is your first baby or you’ve been through birth before.
Senior Registered Midwife, Hannah O'Sullivan explains, “The very first stages of labour are when your body prepares for the main event. Just like you wouldn’t start a marathon without training, your body needs to warm up before it launches into labour. That’s why your first labour is usually longer than any subsequent labours. Your uterus has to develop that muscle memory.
"The second stage of labour is usually the longest. This starts from 10cm dilation and ends when the baby is born. The time this takes can really vary - and, this is the part where you will experience the strongest, most intense contractions. The third stage of labour ends with the delivery of the placenta. That’s a vital end to your birth experience as it tells your body birth has happened, starts recovery and triggers milk production.”
1st stage of labour - the latent phase
The first stage of labour is made up of the 'latent phase' and 'established labour' (also known as the 'active first stage'). According to studies, there is no universally agreed medical consensus on the different stages of labour; definitions vary by hospital and country.
In the UK, the National Institute of Clinical Excellence defines the latent stage as including "painful contractions and some cervical change... up to 4 cm." The next part; established labour is defined as "regular painful contractions and progressive cervical dilation from 4 cm". Overall, this first stage of labour ends when your cervix is fully dilated to 10 centimetres and is 100 per cent effaced (at its thinnest possible point).
What is cervical dilation?
Your cervix is the narrow part of the uterus, at the end of the vaginal canal. In pregnancy, your cervix is firmly closed and sealed with a mucus plug (a collection of mucus that stops bacteria from harming you or your baby). Labour begins when uterine contractions, prompted by hormones, start to thin (efface) the cervix and prompt it to open (dilate). Your cervix will need to dilate all the way to around 10cm to allow your baby's head to be born.
Hannah O'Sullivan, Senior Midwife from the Positive Birth Company, explains, "In the first stage of labour, your cervix is moving forward and thinning. It goes from about 3-4cm long to paper-thin; from firmly closed to 4cm open. It will eventually reach 10cm dilation, which marks the start of the second stage."
If you’ve already been experiencing Braxton Hicks (also known as "practice contractions") throughout your pregnancy, it can be hard to know the difference. Read our feature on the different types of contractions to understand how to distinguish real contractions from "false labour".
What’s happening to your body during the first stage of labour?
Early labour is different for everyone but there are some common things that happen to most women. Early signs of labour can include:
- Real contractions
- Loss of the mucus plug (sometimes called "a show") which is often streaked with blood
- Pain in your lower back
- Uterine pain which many women say feels the same as period pain
- Diarrhoea and sometimes nausea and vomiting
- Waters breaking (slow or fast leak of fluid from your vagina)
At this point, your baby is moving into the right position for labour and 'engaging' their head in your pelvis. In some pregnancies, your baby will engage weeks before labour begins, whereas other babies don't move into position until contractions begin. There's a range of normal.
What should you do in the first stages of labour?
The most important thing to do in the first stages of labour is stay calm. It's tempting to phone your midwife and, if you're having a hospital or birth centre birth, rush out the door with your hospital bag. However, studies show that going into hospital too early can lead to unnecessary interventions.
NICE guidelines recommend that women who go to an obstetric unit (hospital) or birth centre before they are in established labour (4cm dilation or more) should be sent home. It states, "Encourage her to remain at or return home unless doing so leads to a significant risk that she could give birth without a midwife present or become distressed" - NICE guidelines, Intrapartum care for healthy women and babies.
This first stage is best handled in the comfort of your own home, as your very first contractions (or surges) will be infrequent but be starting to form a pattern.
Managing the pain, excitement and emotions as you prepare to meet your baby can be a juggling act. Some calming things that can help include:
- Having a warm bath or shower
- Massage with your birth partner
- Eating regular snacks to build up your energy
- Resting and, if you can, sleeping as much as possible
Hannah O'Sullivan, Registered Midwife tells us, "Until labour calls for your attention, try to carry on as normal. Established labour is when you are having regular contractions: about 3 in every 10-minute period. That's when you should be going into hospital or the birth centre (or calling the midwife if you're having a home birth).
She adds, "When it's your first baby especially, it’s so exciting. You start timing those contractions and focusing on the pain and that can mean you go into hospital too early. Try not to think about it all too much: go for a walk, eat some nutritious food, and try to think that it could be the start of a long journey. Resting and hydrating in a cosy space is ideal. Draw the curtains, perhaps burn some essential oils, maybe think about some gentle pregnancy yoga. Call the midwife for advice if you are worried about anything but enjoy these final moments with your partner before you become new parents."
Some women will experience a lengthy latent stage of labour, that can stop and start, known as "prodromal labour". This won't affect your chances of having normal labour, but it can be frustrating, uncomfortable and disappointing. If you're experiencing this, contact your midwife for advice.
When to contact your midwife
Although it's advised not to go to the hospital too soon, always seek medical advice if you feel something isn't right. You know your body, and by the time the first stages of labour begin, you'll also be very familiar with how often your baby moves.
When your waters break, they should be clear or sometimes a bit pink. If you have any hint of green in your waters or lots of blood, contact your maternity assessment unit for immediate assistance. This could be a sign that your baby or you are unwell. Other signs requiring immediate medical assistance include:
- Pain that doesn't go away in between contractions (especially if you have previously had a caesarean)
- Bleeding (other than streaked mucus discharge)
- Waters that are stained green or black, or smell, as these can be signs your baby is distressed
- If you feel generally unwell or are worried for any reason
- Your temperature is high or you feel feverish
- If your baby has stopped moving or is moving less than usual
2nd stage of labour
The second stage of labour is all about the pushing - it begins when you are 10cm dilated and ends when your baby is born. With first babies, the pushing stage might last up to three hours. For mums who have already laboured before, it's usually about 2 hours.
The second stage of labour is an important time for babies because, as research shows, it prepares their lungs for life outside the womb. Contractions squeeze your baby's body, helping them to expel amniotic fluid and mucus from their lungs as they are born. There is also an impact on your baby's immune system when they go through the second stage of labour. Studies confirm that the vaginal canal contains important bacteria (microbiome) essential for their future digestive health.
When to start pushing during the 2nd stage of labour
At 10cm dilation, your baby will begin to move headfirst into the birth canal. You will then start to feel the urge to push. This urge is prompted by nerves within your pelvic floor that are activated by the presence of your baby's head. This is either called the "fetal ejection reflex" or "Ferguson reflex", which research shows is prompted by the release of a hormone called oxytocin, produced during labour.
You can usually start pushing as soon as you feel that it's right. Your midwife may also offer you advice on the best technique for you. A review of 21 studies that examined the births of 3,763 women concluded that there was no evidence to support any one style or timing of pushing during labour. It suggested that "the woman's preference and comfort and clinical context should guide decisions"
Naomi, mum of three - "What I hadn't realised until part way through my first labour was that with each contraction, when you stop pushing, the baby goes back up. So what I learned to do was to hold the baby in place between the contractions, which made labour progress a bit faster and helped me feel more in control. I also made a noise a lot like a cow, which took me and my husband by surprise. That vocalisation helped at the time, though it seems quite funny now, looking back."
Monitoring the progress of labour
If you have had an epidural, you may not feel the urge to push and you will be guided into your contractions and when to push by your midwife. A special machine called a CTG (Cardiotocography) monitor can be used to show when contractions are starting and ending. It also monitors your baby's heart rate.
Depending on your pregnancy, labour and baby, you may be recommended to have a CTG monitor on you throughout the birth. For some women, intermittent monitoring is recommended (usually for every other contraction). This will depend on what you want and what your healthcare team recommend.
If labour is slow, there are a range of interventions that can speed it up. As outlined by NICE, these include:
- Breaking of your waters ("amniotomy" or membrane rupture) if this has not already occurred.
- Use of synthetic hormones via an intravenous drip (oxytocin delivered through a cannula in your vein) to restart contractions.
Risks of prolonged second stages of labour
These interventions to speed up labour are usually only suggested if there is slow or reduced progress in your labour.
Prolonged stages of labour can raise the risk of:
- Postpartum bleeding (haemorrhage)
- Problems with the baby's ability to breathe, meaning a low "APGAR" score, a measure of the baby's wellness after birth. One major study of 32,796 births showed a clear association between prolonged second stage of labour and low APGAR scores.
Finding a position to give birth in
We've all seen it in movies and on the TV: sweaty mums in labour giving birth lying down. Sometimes with her legs up in stirrups, too. Although research indicates that 68 per cent of women give birth this way, (the lithotomy position), other positions are far more helpful.
In fact, some studies suggest laying down can increase:
- Severe perineal trauma (the area between the vagina and anus)
- How long labour takes
- The amount of pain experienced in labour
Though evidence on the best positions for labour is limited, research indicates that reclined positions decrease available oxygen to mother and baby, compressing the mother's aorta (the main artery in the heart).
Upright positions during labour help to:
- Maximise the effectiveness of your uterine contractions (according to research by Lawrence et al) and
- Get your baby in the best position (better fetal alignment, study by Gizzo et al)
Registered Midwife Hannah O'Sullivan says it's important to follow what your body wants: "finding the best position to labour in is about what's comfortable for you. Whether that's standing up, crouching, kneeling or on all fours, what feels best at the time is what's right for you."
What happens when your baby is born?
The point of birth is called "crowning" and this is when you experience what some women call "the ring of fire". Crowning can be quite intense and painful as it is the widest your vagina will have ever been stretched.
Your midwife might ask you to stop pushing just before the baby's head is fully out of your vagina. This is to reduce the chance of any perineal tearing. Perineal tearing can happen when your baby's head emerges too quickly. It can be a small tear or a larger one, requiring stitches after birth.
Sometimes, your midwife might recommend an episiotomy to help your baby's head be born. This is a small cut to the vaginal opening that will be stitched after your baby is born. You will be given a local anaesthetic beforehand if you have not had an epidural.
After your baby's head is born, usually the rest of their body will be born within a couple of contractions. If you and your baby are well and in no need of any medical assistance, you will be encouraged to have skin to skin contact with your baby, while you await the third stage of labour (delivery of the placenta).
Hannah O'Sullivan, Registered Midwife told us, "Many mums just love the wonderful skin to skin contact they get just after their baby is born, at the end of the second stage of labour. There are loads of benefits of skin to skin contact; for bonding, baby's wellness and initialising breastfeeding. Skin to skin helps regulate baby's heart and breathing rate as well as their temperature, too. If you can get baby feeding soon after birth, that can help contractions push the placenta out in the third stage of labour."
3rd stage of labour
The third stage of labour is the period directly after birth when the placenta separates from and then comes out of your uterus. Your baby is attached to the placenta via the umbilical cord and this will usually be cut before the placenta is delivered. There are two ways that the placenta can be delivered: active management (using medication to speed delivery of the placenta) or physiological management (waiting for your body to complete this process).
You can change your mind on whether to accept active management of the placenta or not at any time up until the medication is given. It's a good idea to discuss your options and any worries about accepting this medicine with your midwife. Once you have made a decision, you can document your decision in your birth plan.
What is active management?
The National Institute for Clinical Excellence recommends active management (medication to prompt delivery of the placenta) for all women undergoing vaginal birth. This is because active management shortens the third stage and reduces the likelihood of severe bleeding after birth (postpartum haemorrhage). The World Health Organisation defines postpartum haemorrhage (PPH) as being greater than 500ml.
If you choose active management, you will be given an injection of oxytocin (a hormone), usually in your thigh. You can choose active management of the third stage wherever you give birth (home, hospital, midwife-led unit). Your midwife will expect the placenta to be expelled within 30 minutes of the injection being given.
NICE say that active management causes nausea and vomiting in some women (1 in 10 women). It can also make afterpains (caused by the womb shrinking and contracting after birth) feel more painful. A 2019 Cochrane study of over 10,000 women found that the evidence for the reduced risk of postpartum haemorrhage was low, compared with physiological management (waiting for natural processes).
What is physiological management?
Physiological management means waiting for your body to naturally expel the placenta. You have the right to choose physiological management. NICE guidelines say "If a woman at low risk of postpartum haemorrhage requests physiological management of the third stage, support her in her choice."
Your midwife will expect your placenta to come out within an hour after birth if you choose physiological management. When your placenta takes longer than an hour to emerge, you will be advised to opt for active management.
Risks of choosing physiological management include:
- Nausea and vomiting (50 in 1,000 women).
- Risk of 29 in 1,000 of more than 1 litre of blood loss.
- Risk of 40 in 1,000 of needing a blood transfusion (replacement of your blood).
Source: NICE, UK
Removing 'retained placenta'
Once your placenta has been delivered, your midwife will inspect it to ensure it is all complete and appears normal. This is very important as "retained placenta" (where some or all of your placenta remains inside you) can be very dangerous. Research indicates it is the "second leading cause of postpartum haemorrhage" and happens in 1-3 percent of deliveries. In rare cases, it can mean mothers lose their lives.
Studies show risk factors for retained placenta include:
- Having previously had a retained placenta
- Preterm delivery (before 37 weeks of pregnancy)
- Previous surgery on your womb
- A history of pregnancy termination
- If you've suffered a previous miscarriage
- When you've had more than 5 births before (known as "grand multiparity")
You will need to go to the theatre if you have retained some or all of your placenta. Obstetricians may have to manually remove your placenta (or parts of it).
Your placenta after birth
When your placenta comes away from your uterus, it signals to your body that your baby has been born and recovery begins.
Research reveals it also prompts lactogenesis (milk production), which means retained placenta can delay and reduce your milk supply.
You can opt for your baby and the placenta to remain untouched if you would prefer (known by some as lotus birth). If this is your decision, do discuss the pros and cons of lotus birth with your medical team. You can also decide to keep your placenta after birth, too. Some women make art with it or eat their placenta, plant it under a tree, or do placenta encapsulation. It's entirely up to you what you choose to do.
Related video: How to ease stitches after labour
