Labour is the normal process that causes a baby to be born. There are regular, painful muscle contractions and dilation of the neck of the womb (cervix). It usually happens sometime around the 40th week of pregnancy. There are many ways to have pain relief and your midwife can help you choose which is best for you. Most women are delivered by midwives, who also look after them during their pregnancy. They are the experts in normal, vaginal delivery. It is a good idea to have at least one trusted friend or member of your family with you during labour.
What is labour?
Labour is the normal process that causes a baby to be born. It is made up of regular, painful muscle contractions in the womb (uterus) and gradual opening (dilation) of the neck of the womb (cervix).
The muscle contractions slowly push the baby down through your hips (pelvis), through the neck of your womb and into your vagina.
Labour usually takes place sometime around 40 completed weeks of pregnancy. Anytime between 38 weeks and 42 weeks is considered normal.
How do I know I'm in labour?
Contractions usually start the process. Although initially they may come at irregular intervals, they do become regular. At first they may be 10-15 minutes apart but they will become closer and closer together. As they become closer together they may also become stronger, longer and more painful. The contractions cause your womb (uterus) to feel hard.
Many women may have a 'show' before labour starts. This is a thick plug of mucus, often with a bit of fresh blood in it. It has come from the neck of the womb (cervix). It may happen some time before labour starts but shows your body is getting ready to have the baby.
Some women may find their 'waters break' before contractions start. There is usually a gush of fluid that soaks your underwear, followed by a constant trickle. This means you will need to wear a pad. The fluid is amniotic fluid which was surrounding the baby. It provided a cushion for the baby and also helped keep your baby warm. Your baby could also practise swallowing, or passing urine through this fluid.
Once your waters have gone there is no protective layer between the baby and the outside world. Most women will go into labour within 48 hours of their waters breaking. If you do not, your hospital doctor will talk about starting your labour for you - inducing your labour. This is because the risk of infection for the baby increases after 48 hours. It is better for your baby to be out of your womb then.
If you think you are in labour you should call your midwife for advice.
How long does labour last?
There are three stages of labour. The amount of time taken for each varies from woman to woman. It also tends to be longer for women in their first pregnancy than for those who have already given birth.
The first stage
The neck of the womb (cervix) softens up and gradually opens (dilates). The softening process may be quite slow and it may be several hours until you're in what midwives call 'established labour'. This is usually when the cervix is 4 cm dilated. If you go to hospital before labour is established, it may be better to go home than spend hours there unnecessarily. Try to keep moving about. A bath or shower can be relaxing.
Once labour is established your midwife will check your progress regularly. In a woman's first pregnancy established labour may last up to 12 hours. In women who have already had a baby this can take up to 9 hours. The first stage ends when the cervix is 10 cm (fully) dilated.
Most women are able to be up and about for most of this stage. You can drink and have small things to eat. As the contractions become more painful you can use relaxation and breathing techniques to cope. When this no longer helps you may need to think about pain relief - see below.
The second stage
This begins when the cervix is fully dilated and ends with the birth of the baby. You will need to find a position that works for you. Women can lie, stand, kneel or squat to deliver their baby.
You will feel an urge to push down. Your midwife will talk you through how to do this most effectively. You can start to push when you feel you need to during contractions. Take a deep breath when the contractions start, and push down into your bottom. Take another breath when you need to. Try to give three good pushes before the contraction ends. After each contraction, rest and get your strength up for the next one.
This stage is hard work. You will need lots of support from your partner and your midwife. In this stage the baby's head moves down until it can be seen. When the head is about to be born (is crowning), the midwife will ask you to stop pushing. They will ask you to pant or puff a couple of quick short breaths, blowing out through your mouth. This is so that your baby's head can be born slowly and gently, giving the skin and muscles around your vagina time to stretch without tearing. The skin of the perineum usually stretches well, but it may tear. Sometimes, to avoid a tear or to speed up delivery, the midwife or doctor will inject local anaesthetic and make a cut. This is called an episiotomy. Afterwards, the cut or tear is stitched up again and heals.
Once your baby's head is delivered the hard work is over. With one more push, the body is born quite quickly and easily. You can have your baby lifted straight on to you before the cord is cut by your midwife (or birthing partner). Skin-to-skin contact is important and helps you and your baby to bond. Your baby may be born covered with a white, greasy substance known as vernix, which has acted as protection in the womb (uterus). Your baby is dried and wrapped, to stop them getting cold.
The third stage
This lasts from the birth of the baby, until the afterbirth (placenta) is delivered. The midwife will ask you whether you want an injection to help speed up this process. The injection is called Syntocinon® and it is given into your thigh. Syntocinon® makes the womb contract firmly and pushes the placenta out. This also helps prevent bleeding at this stage.
Allowing your baby to breast-feed at this stage also makes the womb contract and reduces the risk of bleeding.
Where can I have my baby?
Many women will find it reassuring to have their baby in a hospital. Having a baby can be a worrying time, particularly for first-time parents. In a hospital there are all the necessary people and equipment to deal with any problems quickly, if they arise. However, some women prefer to have their baby at home or in a midwife-led unit. If you have already had one child who was delivered normally and this pregnancy is straightforward, it is generally just as safe to have your baby at home or in a midwife-led unit.
Most hospitals have a midwife-led unit. Midwives are experts in normal pregnancy. If they feel something is not going to plan they will ask a doctor to come and look. If the doctor agrees something needs more attention, they may move you into the hospital labour ward. Here, they have all the necessary equipment to monitor your baby and do whatever is needed.
Some women choose to have a delivery at home. If you are assessed as being low-risk for complications and live close to your local hospital, this is a safe option. You can only have gas and air (Entonox®) and injections for pain relief at home. Epidurals are not possible. Your home will need to have a suitable room for you to deliver in, or you will need a large plastic sheet to protect your carpet/floor. Your midwife will transfer you to hospital if they are unhappy at any time; that is, they are concerned for you or your baby.
If you choose to have your baby in hospital, your local hospital is the obvious choice. You may feel that when the time comes you will want to be somewhere close to the hospital. If you have more than one maternity unit locally, you may want to visit it before you make a choice.
What pain relief can I have in labour?
Women who have continuous support during labour from someone experienced in providing that support are less likely to need pain relief. Understanding what is going to happen, being able to relax and being in the place that you want to be to give birth may all make labour less painful.
In the early stages of labour it can be very soothing to be immersed in water. Many delivery units have a pool. It may be available just for pain relief early in labour, or sometimes women may deliver in it. There is usually only one, so if it is already in use, you may not be able to use it. If you think you may want this, ask the midwife when you visit the unit.
Many women find a transcutaneous electrical nerve stimulation (TENS) unit helpful before labour becomes established. TENS is thought to work by stimulating the body to produce more of its own natural painkillers, called endorphins. It also reduces the number of pain signals that are sent to the brain by the spinal cord.
Use of gas and air (Entonox®) is always available, wherever you choose to give birth and at any time during labour. It is a mix of oxygen and nitrous oxide. It is very simple to use: you breathe it in deeply during the contractions and breathe it out again. It works very quickly and wears off in a few minutes. It may make you feel light-headed. It will provide enough pain relief to help you through the worst of the contraction. It has no harmful effects on your baby.
Pethidine or diamorphine is given by injection, takes about half an hour to work and lasts for 2-4 hours. Sometimes it can be given by a pump that you control yourself by pressing a button on the pump. It is helpful in the earlier stages of labour and helps you relax. It may make you sleepy and feel sick. If given too close to the birth of the baby, it can affect the baby's breathing. If this happens, there is an antidote available to help. It may also make your baby drowsy so that he or she can't feed as well as normal.
An epidural is a type of local anaesthetic. You have an injection into your back that numbs the lower half of your body. It is the most effective way of relieving pain. It can last for the whole of labour, if topped up regularly. Most women have complete pain relief after one is in place. Some hospitals have a 'walking epidural' service but most women will not be able to walk when they have an epidural. Having an epidural makes the second stage of labour longer and you are more likely to need medication to make your contractions stronger. Having an epidural also increases the chance that you will need a doctor to deliver your baby using a ventouse or forceps (see later 'How do you know your baby is OK during labour?'). However, it does not increase the chance that you will need a caesarean section.
What if labour starts too soon?
Labour is said to be 'too soon' (premature) if it comes before 37 completed weeks of pregnancy. Most babies can breathe for themselves after 32 weeks of pregnancy. The main challenges for babies born between 32 and 38 weeks are keeping warm, feeding and not picking up an infection.
Before 32 weeks of pregnancy the baby's lungs may not yet be fully developed. They may need help with breathing and extra oxygen. You may be given an injection of a steroid called dexamethasone or betamethasone. This helps the baby's lungs to mature quickly. In addition, the premature baby will also have to feed, keep warm and ward off infection. Their gut is also not fully developed and they may need to be fed through their blood vessels (veins) instead of the normal route.
Babies are now surviving even when they are born extremely prematurely; that is, at 22-24 weeks of pregnancy. The heavier they are, when born, the better their chance of surviving. Babies that do survive still have very many challenges to face and it is common for many extremely premature babies to be left with some disability.
What if labour doesn't happen and I'm overdue?
Labour normally happens before the 42nd week of pregnancy. If your labour doesn't start, you will be examined to see how likely it is that labour will start soon. You will be offered induction of labour; that is, they will start your labour artificially. This is either done with a hormone (prostaglandin) gel that is placed into your vagina, or by breaking your waters and giving a medication into your vein.
The gel contains a hormone that makes the neck of the womb (cervix) soften and start to open up (dilate). Your contractions will start and become stronger and stronger, as normal. The pessary is given in the hospital ward and you are taken to the labour ward, when your labour has started.
Your waters are usually broken on the labour ward. A midwife or doctor uses something that looks like a crochet hook to make a hole in the bag that holds the water. This does not hurt the baby, or you. Usually your contractions start after that but if they don't a drip will be put in your arm. This allows a different hormone to be given, which will start your contractions. The midwife can control how much hormone you receive and therefore how strong your contractions are. The contractions will need to be strong and close together to deliver the baby. Contractions may be more painful if medication is used to start off (induce) your labour or to speed it up.
How do I know my baby is OK during labour?
Your midwife will listen to your baby's heartbeat regularly but not all the time. How fast, how regular and whether there is any slowing of the pulse, will tell the midwife a lot about how the baby is doing. They will normally use a small machine called a Sonicaid® to hear the heartbeat. This has a probe which is placed on your tummy, a bit like an ultrasound scan. You will be able to hear the heartbeat too. It sounds very fast but it is normal for a baby's pulse to be 120-160 beats per minute; that is, twice as fast as an adult's.
Some pregnant women will need their babies to be monitored constantly. A machine called a cardiotocogram (CTG) is used then. Two round, flat probes are attached to your tummy by belts. One measures if you're having a contraction and the other measures the baby's heartbeat. If your waters have broken and a better monitoring of the heartbeat is needed, the probe can be attached to the baby's head. This is called a fetal scalp electrode (FSE). It gives a better recording because it is directly attached to the baby and doesn't have to go through your tummy wall. The FSE is not thought to hurt the baby because it just clips on to the scalp.
If your midwife and doctor become worried about your baby, they may take a sample of blood from the baby's scalp too. They can only do this if your baby is coming out head first, your waters have gone and the neck of your womb (cervix) has opened up (dilated) a little. They can analyse this blood (only a few drops) to see if your baby is getting too tired. If this is the case and you are not fully dilated, they may advise you to have a caesarean section. If you are fully dilated it may be possible to have a ventouse or forceps delivery.
In a ventouse delivery, a suction cup is placed on the baby's head and used to gently pull the baby out, while you push. A forceps delivery involves metal instruments (a bit like salad spoons) being placed around the baby's head. They are used to gently pull, while you push too. Ventouse and forceps deliveries are sometimes called instrumental deliveries.
What should I do now?
If you think you are in labour, or just need some reassurance, you can phone your midwife. Their number is usually on the front of your notes. If their number is not there, you could phone the labour ward where you are due to deliver.
You can have a relaxing bath or shower, if your contractions are still spaced well apart. The warm water is quite soothing.
Check your bag is packed. Many women forget things like sanitary towels. You will need them after your delivery, as it is usual to bleed for about two week afterwards. Don't forget some baby clothes and nappies.
Who will look after me in labour?
Most women are cared for by midwives. They are highly trained and expert in normal delivery. If they are worried by any aspect of your pregnancy or labour they will ask an obstetrician to see you. Obstetricians are doctors who specialise in pregnancy and childbirth. They perform procedures and deliveries when needed.
Labour wards will allow your partner and possibly one other person to stay with you during labour. These people are important sources of support for you. They can talk to you, hold your hand and rub your back, if you want it.
What if labour doesn't go well?
'Not going well' means different things to different people. If this is your first pregnancy, try to stay relaxed, ask questions as you go along and have few fixed ideas about what you think will happen. During your pregnancy try to gather as much information as you can about what happens and what your options are.
If you are advised to have a caesarean section, this will be because it is the safest option for you and your baby. Not having a normal vaginal delivery should not be seen as a failure. There are many factors that can prevent a normal delivery and you can do nothing to change most of them.
What happens after labour?
You will be encouraged to feed your baby as soon as possible after delivery. Your choice of feeding is best discussed well before labour. Friends, family and your midwife are all good sources of advice.
You may need stitches if you had a cut after a local anaesthetic (an episiotomy) or a ventouse/forceps delivery. Sometimes women tear as well during delivery of the baby's head. You will be given local anaesthetic if you need it - for example, if you don't have an epidural.
After delivery you will be taken back to the ward. You will be able to feed your baby, if you haven't already. One of the nursing staff will wash your baby. At some point a doctor who specialises in children may come to examine your baby. This is a top-to-toe examination designed to pick up anything that isn't quite right. If problems are found you will be asked to bring your baby back to a specialist clinic.
How long you stay in hospital will depend on what type of delivery you had and how well you are. If it is your first delivery you may need to stay a little longer, even if it was a normal vaginal delivery. Different labour wards have different policies about discharge. You can ask them about their discharge policy when you visit.
Dr Hayley Willacy
Dr Jacqueline Payne
Dr John Cox