First stage of Childbirth

When does labour begin?

The official line is that first stage starts when your cervix begins to dilate and ends when the cervix is fully dilated. This entire stage can be further divided: ‘early labour’ and ‘active labour’. Active labour has a Early labour is characterised by contractions which are spaced between 5 mins and 20 minutes apart. Most women are aware of them; however they often don’t hurt too much. For some women it can feel like a crampy sensation or a tingling sensation. Most women in early labour can continue on with day to day activities with no problems and many women will try to find a balance between light activity and rest. Internally the uterus is bringing the baby down into the pelvis and the early contractions thin the cervix at the top of the birth canal so that it can open.

Signs that labour is starting:

A bloody show with contractions. This is a loss of the mucus plug which seals the opening to the cervix and will be a small loss of blood or a pinkish discharge. If there is a large amount of blood, there could be bleeding from another source such as from the placenta and you will need to consult with your health care provider. The contractions don’t always happen at the same time as the show, they can begin hours later.

Leaking of amniotic fluid. This can also be a gush if the membranes have ruptured completely. This can happen any time during labour from before contractions begin through to just before the baby is born. It can even happen every now and then that the baby is born with the membranes still intact.

Again, this is welcome sign. It is the breaking of the waters and shows that labour has either started or will soon start. Often, this will speed up the labour process and may represent a step up in intensity for many women.

If the fluid that is leaking is green or brown it could indicate that the baby has passed a bowel motion and you will need to consult with your health care provider. Some health care providers are very concerned by this while others are not so. Some birth professionals believe that this is a sign that the baby is in difficulty or that the baby has had some difficulty. This can be hard to tell without proper questioning and examination and even then it can often be guess work. I suggest discussing this with your care provider and listening to your intuition. You may well know within yourself if things are O.K or if something is not right.

Loose stools and frequent urination. This is your body cleaning out and making room for the baby to come into the birth canal. This is a very welcome sign in early labour.

Other signs may include:

• A dull backache at regular intervals
• Contractions which become longer and stronger and closer together
• Period type pain in the back or in the lower abdomen
• Contractions may be irregular to start off with but will become more regular as things progress. Walking will make the contractions stronger and lying down will often slow them down or make them disappear.
• It may feel as though the contractions start in the back and radiate to the front.

As first stage becomes more established you may also notice:

• A feeling of increased pressure in the pelvis as the baby’s head comes further down.
• Abdominal pain that may move into the back
• Increased pain in the back and hip discomfort
• Pain in the groin and in the inner thighs
• Restlessness, concentration or a kind of meditative state are common.

Once you have started the first stage of labour there is generally a marked change every hour or two. If you find that you are doing the same thing you were doing an hour or two ago then it is likely that you are experiencing pre-labour.

The amount of time in first stage varies enormously from women to women. Whatever the pattern of your labour, your contractions will become more powerful, longer and closer together as the cervix opens from closed to 10cms (Inches) wide.

As you get closer to full dilation (usually from 5-10cm), the contractions can become really intense and begin to require all of your concentration. This is active labour. Most women no longer feel that they are able to continue with their normal activities and will settle into labour with each contraction becoming stronger, longer and closer together. This is the time when you might become irritable, or go quiet or begin to make sounds. Breathing changes and becomes deeper and stronger. Active labor is the most difficult part of first stage and you will be working really hard. It is very physically demanding, painful and can be a very intense experience.

Managing early labour

Rest. Labour can take a long time and can be exhausting. You’ll need all of your energy so if you experience early labour during the night it’s night time it can be great to get some sleep, if it’s daytime, you can rest when you feel like it and do things that might help to distract you but that are not physically, mentally or emotionally demanding. This is a good time for mindless busy work.

Ideas for biding your time and staying relaxed in early labour

• Take a soothing shower or a relaxing bath.
• Try a cup of herbal tea. This is a great time for our Transition tea .
• Gather the things you need, make sure you have the things you want to take with you if you are going to a birth centre or hospital. It might be a good time for you to make sure you everything you need ready if you are having your baby at home, your midwife will let you know what these things are well in advance.
• Do some yoga, especially good if you have practiced this during your pregnancy
• Hobbies- Such as needlework, painting or knitting, as I said earlier, mindless busy work is what you need.
• Watch a movie
• Call your birth team. Let everyone involved in the birth know that your are in labour even if you don’t need them yet.

This can be a great time to learn about the rhythm of your labour. You will notice two phases. The working phase happens while the uterus is contracting, helping the cervix dilate. The resting phase happens during the time between the contractions. During the working phase it is best to try to relax and to breathe easily through the contraction. For comprehensive information about the breath during labour, get your self a copy of The Pink Kit . I consider this an essential tool for every parent and support person experiencing labour.

During the resting phase, if it is still 15-20 minutes or so you may wish to continue with day to day activities remembering to take things easy and take time to calm and centre your self. As the labour progresses, you may start to use the resting phase to turn inward and rest. Some women find they go into a kind of meditative state in between contractions.

You can learn how to feel where you are in your own labour by practicing the techniques in The Pink Kit CD and DVD during your pregnancy and using them throughout your labour.

You might also find this a good time to review your knowledge of labour and you management plan.

Understanding pain in labour

It’s not called labour for nothing. Childbirth demands your uncompromised physical stamina and emotional control. I have heard that it’s not always painful but I am yet to meet anyone who has had a pain free childbirth experience.

The natural therapies I have outlined in ‘Natural Therapies for Childbirth‘ will not take the pain away but they will help you to manage it more effectively, they may also help to correct the underlying problem that is causing the pain to be intolerable. Aside from this, I think it really helps to deal with and accept the pain of childbirth if you have an understanding of what it is and you keep your eye on the prize. Your beautiful baby will be born alert and able to breastfeed immediately. You will feel awake and alert, able to enjoy your new baby. You may experience amazing feelings of accomplishment, have an easier start to breastfeeding, easier bonding, less chance of post natal depression. You’ll be able to get up and take a shower after labour.

The pain of labor is intense for most women but it can be managed. I was sure I had a terribly low pain threshold going into childbirth with my first son. I am sure it was only through being able to intellectualise the pain of transition (and a well chosen homoeopathic remedy) that I didn’t accept the offers of pain relief from my midwife. Many women have found that if they can understand the source of the pain they can interpret it and respond to it in a positive manner.

There are two main types of hormones we want to encourage in labour. Oxytocin is the hormone that causes strong, regular and effective contractions and endorphins are your body’s own morphine like drugs that help to deal with the pain and ‘put you in the zone’. The hormones we want to avoid are the hormones that your body makes in response to stress and danger, the major player being adrenaline.

The fear-tension-pain cycle

Many women are scared of the pain of childbirth. This fear causes tension which tightens the cervical muscles which causes more pain and so the cycle goes on. This can lead to an abrupt stop in the process of birth. The contractions become harder and longer as they try to breakthrough the muscle tension which creates more pain causing more fear of the contractions.

This is often the point at which the first of several medical interventions is administered. Maybe gas, pethidine or an epidural. Each of these pain relief options has its own side effects often resulting in further interventions. See medical interventions of childbirth for my explanation of the risks and benefits of these.

Fear also causes the body to secrete the stress hormone adrenaline which slows labour down and causes many symptoms which are often misunderstood as being problems requiring intervention. It is actually a normal response to stress and perceived danger.

Adrenaline is released by your body in response to danger. It is the fight or flight hormone and its role in labour is to stop the mother from giving birth in a dangerous situation. As your body makes more adrenaline, you make less oxytocin, the hormone which gives regular, strong, rhythmic and effective contractions.

Some of the common effects of adrenaline during labour are:

• Panic
• High blood pressure
• Slowing of contractions due to the effect of adrenalin on oxytocin production
• Increased pain caused by reduced flow of oxygenated blood to the uterus
• A pause in dilatation as the circular uterine muscle fibres contract and counteract the action of the other muscle layers
• Contracted pupils
• Cold, clammy skin

If you notice that your contractions are slowing down and becoming more painful, that you are not progressing as quickly as you were and you are not tolerating the pain as well as you have been then it is likely that you have had a good hit of adrenaline. This is often referrer to as failure to progress, I call it adrenaline dominance. The medical management is to make the contractions faster, stronger and more effective by giving a good dose of syntocin, to do the job of the dwindling oxytocin and to over ride the effects of the adrenaline. The alternative to this is to change the environment so as to eliminate the body’s need to flood with adrenaline and to coax it back to releasing oxytocin and endorphins.

If you find your self in this situation, you may find the following suggestions helpful.

• Put someone in charge of creating an environment which will encourage the production of oxytocin and natural endorphins. This will switch off your body’s stress response and allow labour to happen more easily.
• Identify the source of fear or disturbance and remove it. Often this can be a doctor, a nurse, a routine vaginal examination or just because you are in the hospital. You can ask for the staff to leave you alone and tell them that you will call for them when you feel you need them. EFT can be extremely useful for this purpose. See ‘Natural Therapies for Childbirth’ for details.
• Use basic stress relief measures. Claming breaths, any relaxation exercises you may have practiced.
• Make noises with the contractions, but let them out from the belly rather than the throat. Deep mooing type sounds rather than a scream, yell or screech. This will help you to maintain emotional control. You can practice and experiment with this during pregnancy. Try the two sounds and you will notice the difference in your emotional response.
• Provide privacy. If you want to be alone, ask to be alone. If you would like to be alone with your partner and have no one else visible, let someone know. This can usually be accommodated.
• Avoid unnecessary procedures. If you respond to an adrenaline hit with more stress you will make more adrenaline, things will slow down more and become more painful and less tolerable. If someone wants to do a vaginal examination or foetal monitoring, ask them to explain why and what will be gained by it. If you don’t feel the benefits outweigh the risks, you can say no.
• Change the environment. If you are at the hospital, maybe a stroll around the grounds would help you to get back into the swing of things. Maybe you could move to a different room or have a bath or a shower.
• Dim the lights and have someone provide warmth and quiet.
• Keep people in the room that you find comforting and empathetic.
• Remove anyone who is showing signs of anxiety.
• Ask everyone to whisper, avoid eye contact and conversation.
• Play some calming music
• Try massage, reflexology, acupressure, homoeopathy or aromatherapy. See ‘Natural Therapies for Childbirth for full details on how to use these therapies safely and effectively while in labour.
• Allow time for the balance between adrenalin, endorphins and oxytocin and to reappear -you will probably need to wait at least an hour in the new conditions. Despite what you may feel at the time, you will have time to wait and see how things go and you can get through it.

Active labour

This is the time that your cervix dilates from 3cm to 10cm.

Contractions become closer together occurring at three to five minute intervals and they continue to become stronger and longer lasting about 60 seconds until they are almost back to back.

You may feel the contractions in your abdomen, back or thighs.

Towards the end of first stage there is a period known as transition. This occurs when the cervix is approximately 8-10cm dilated. The contractions last as long as 90 seconds and are really close together. You may experience a desire to push as you feel the baby bear down on the rectum and it is very common to lose control of the bowel.

It is important that if you feel as though you are having a bowel motion that you don’t try to stop it. Just go with it, it will help the baby get through the pelvis into the birth canal. It is also very common to feel nauseas and shivery during this time. This is the toughest part for most women. Luckily, it is also very short for most. See ‘Homoeopathy for childbirth’ for homeopathic remedies that help get through this time.

Keep it positive

During active labour, negative self talk can become a problem. You may find that you have been dealing with things really well up to a point and then you start to tell your self things like “I don’t like this” or “Why is this taking so long” or “Is this normal?” This is a common time for doubt, fear and pain to interrupt the normal balance of hormones that can result in a quick, trouble free birth.

Dealing with fear and worry

If you find that you are plagued by self doubt and anxiety, EFT is a truly wonderful tool to use here. If you have given yourself plenty of practice with EFT before hand and have practiced the set up routine then you should be able to trigger the response without having to do the tapping routine. If you are working with the tapping routine then do it in between contractions and get your birth partner to tap along with you. If you don’t feel like you can tap or say the words, have your partner tap it for you. This will take some practice to perfect so if you intend to use this as a tool in labour then it will really help to practice with your partner before hand. Simulating what you imagine it could be like and how you will use the technique at the time. See here for more information about using EFT during labour.

Many women get very restless and many others get very quiet during this phase. Remember that your body knows what to do and if you have knowledge of the birthing process you can use this to know what is happening to you and your baby.

If you don’t like the way things are going it can help to at least acknowledge this to yourself and then get on with whatever management skill you have planned to use. You can ask you birth partner to remind you of your management plan if you if forget it or decide that you’ve had enough. Work thorough things one contraction at a time. If it all gets too much and you decide to hell with it, you want drugs, it can be a great help to tell your self just one more contraction then I’ll consider it. Things change very quickly during this time and often one or two more really long and painful contractions is all there is before things slow down and the next stage begins.

Transition is the most challenging aspect of labour for most mothers. Many women become irritable and can feel that they can no longer bear it or go on. Often all of the management strategies a woman has planned to use will go out the window. This is why it is a great idea to practice your coping strategies and plan for a moment like this.

Working with The Pink Kit resources is invaluable for preparation and management of the pain and fear of labour. See here for Pink Kit details .

You will also find many techniques for coping with fear and pain during labour in ‘Natural Therapies for Childbirth’.

What position is best for active labour?

There is no one size fits all answer to this common question. The only position to avoid is flat on your back. Standing, squatting, semi-reclined, all fours, side lying with one leg raised are all useful depending on the women. You can use furniture or other people to support you. If it feels right and things are moving along then you’re in the best position.

Generally speaking, try to remain as upright as possible, using positions that keep the pelvis open. No one position is going to be right for every women. There are a variety of positions that are suitable and most women find that they will instinctually find the position which best suits their own unique pelvic structure during the birthing process itself. You will find information on the Pink Kit DVD which will help you to determine your pelvic structure and which position for birth will best suit you. If your labour is progressing then it doesn’t really matter what position you are in.

It can be helpful to practice different positions with your birth partner before the birth itself. This way you know what is comfortable and you can plan a little to ensure that you will have your choices available to you. Eg. You might find that it is comfortable to be supported by holding onto a chair or you find a really easy way for your partner to support you, or you may try squatting and find that it’s not comfortable for you to stay in that position for long.

Below is a summary of the pros and cons of the most popular positions for second stage labour.

Positions for first stage of labour

Position	Pro’s	Con’s
Upright– Walking – supported by partner – Leaning forward against a chair	– Gravity helps to bring the baby in through the pelvis- Encourages even pressure of the head against the cervix which can mean faster dilation.]Improved circulation to the uterus and to the baby- Causes stronger, more effective contractions- Helps to relive backache	– May become tiring
– Sitting upright on a bed- Semi-sitting on a bed	– Gravity helps bring the baby into the pelvis- Less tiring	– Does not encourage movement which may slow down labour- May increase backache- Medicalises the process, the mother may feel more like a patient.
Kneeling– on all fours- against a birth ball- against a bean bag	– Relives back ache- Helps the back to be accessible for massage- May assist the baby to rotate if the baby is in a posterior presentation- Reduces pressure on the large blood vessels thereby improving the circulation, decreasing pain and reducing blood pressure- Allows birth partner to become more involved	– May become uncomfortable over a long period of time
– Sitting back to front on a chair	– Good for labour pains felt in the back- Enables massage as back is accessible- Gravity assists the baby to move through the pelvis	– Discourages movement which can slow down labour
– Leaning forward on cushions	– Very relaxing- Relives backache- Easy to massage mother’s back	– Can cause discomfort in knees over time
Squatting– Supported squatting using a birth stool, books, or steps	– Gravity assists the baby to move through the pelvis- Helps the cervix to dilate more quickly- Relieves back ache- Easy to rock or sway	– Can be tiring
– Knee to chest	– Used in transition to overcome pushing urge if cervix is not fully dilated- Used if cord prolapsed to relieve pressure of the babies head on the cord- Relives back ache- May help the baby to rotate if in a posterior presentation	– May slow down labour- Does not help with cervix dilation

Tips for coping with active labour.

Choose open positions. Those that help to keep your pelvis open and that are comfortable for you.

Consciously release tension. During contractions, relax and let go as much as possible.

Rest between contractions. Make an effort to rest; close your eyes, centre yourself and use any relaxation techniques you have practiced. You might find that you easily fall into a deep meditative state. You can try focusing on your breath or a relaxation exercise . Focus especially on your pelvis, consciously relaxing those muscles you feel working during the contractions and letting go of any tension you feel in your lower back and abdomen. Again, The Pink Kit has some great exercises to do to help familiarise yourself with your pelvis muscles and ligaments and give you some exercises to use during labour to help to let go of the tension you feel in these areas.

Use a deep cleansing breath . I recommend an abdominal yoga type breath to use between contractions. It is a great relaxation breath that you can use all though pregnancy, during labour and post partum. It is also an energising breath, helping to combat fatigue. Practicing abdominal breathing while pregnant will help these muscles get back into shape more quickly after delivery. The more you practice it the easier it will be to use while you are deep in the throws of active labour. Here’s how it’s done.

You can close your eyes or keep them open while you focus on your breath.  When you’re ready, inhale and expand the lower belly away from you and exhale draw the belly back toward your spine.  You want to feel both the release and contraction of the muscles, so you’re clear about each movement.  Breath with your natural breathing rhythm, don’t try to alter it.

If you have a back ache. Try rocking backwards and forwards in whatever position it is you are in. Most women will do this instinctively. Birth balls are wonderful for this. Many women find that rocking on all fours is a great way to relive backache.

Let go . Trust that you know how to give birth and that your baby knows how to be born. Make noise, allow yourself be incontinent (it happens to most people!) vomit if you need to. These icky reflexes allow more room and can help bring the baby down into the pelvis. Let go of any self consciousness you may have, go with flow, let your body do what ever it needs to do and things will likely unfold in a healthy and positive way.

Giving birth is not a dainty experience, a natural intervention free birth tends to be a very primal experience and it can bring with an intense sense of achievement and self satisfaction along with all the positive health benefits for both you and your baby.