Stages of Labour - Preparing For Birth Manual

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Latent Phase

• From 0cm to 4cm dilated

• Contractions are irregular, may stop and start

• Can last anywhere between 5mins and 2 weeks

• During this time levels of the love hormone oxytocin and the body’s natural pain relief, endorphins increase

Also known as the ‘excited phase’ - everything seems to have started and we can feel a rush of joy and anticipation. In this early stage the cervix dilates (or opens) up to 4cm and during this time the period-like cramps can be irregular; they may start and stop and last anywhere between 20 seconds to a minute. This phase can last a few days, or a week or two - and may just present as a few irregular contractions or back aches from time to time. Or it can all happen very quickly - in as little as 5 minutes.

When contractions do start, it is useful to note how long each one lasts, and how long in between each. Keeping track of these timings is a great job for the birth partner to do (there are some great apps out there to help with this).

While contractions are still ‘irregular’ the whole process can stop and start. This is just the body’s way of having a warm up. So go with the flow as much as you can. Strike a balance between having a rest when you need to and doing some gentle activity. Eat little and often, sticking to light, nutritious, easily digestible foods and be sure to drink plenty of fluids and keep peeing.

Now it the time to really make sure you are ready for the big day. So be prepared - have food in the house, a bag packed (even if you are planning a home birth it is helpful to have everything all in one place and /or for in the event of you transferring into hospital) and make arrangements for any older children.

Once the contractions begin to settle down into a more regular pattern of coming every 20 mins, and then progressively getting closer (i.e. coming every 15mins, every 12mins, every 10mins, every 8 mins, every 5 mins, every 2-3 mins), longer lasting (between 40-60 seconds) and becoming more powerful, you know things are becoming ‘regular’. When this happens you will probably want to call the midwife or labour ward to let them know that you think you are in labour. As a rough guide, it can be useful to make sure they have been coming every 5mins for up to 40-60mins and lasting around 40-60 seconds each.

When you feel your contractions coming in, begin your Birth Breathing practice to keep yourself calm and increase the oxygen going to your uterus. Try to be upright and leaning forward to help encourage your baby in to a good position (Optimal Foetal Positioning - OFP), but no deep unsupported squatting yet (save this for later).

You may not feel like yourself - may want to eat, then not. May want to drink, then not. May be hot, then cold. This is just the changes in your hormones. Eat small snacks or a light meal if you feel like it. However, as things progress you may even vomit or have diarrhoea - this is your body’s way of clearing the digestive system, so all the focus and energy and oxygen in the blood supply, can be directed to the uterus instead of the digestive system. Clever, eh!

With each contraction the uterus muscle fibres that go up and down its length are shortening, essentially making the uterus smaller to help push the baby down. At the same time, the uterus muscles that go around are also getting shorter, which helps to soften the cervix and draw it back, opening it completely to make space for the baby to descend downwards into the birth canal.

So as the contractions progress, reassure yourself and your baby with meditation, positive thought and positive affirmations - “It is happening, my baby is coming, my body is opening, I’m birthing my baby, I am calm and my baby is calm.”

Stay at home for as long as you can (if you are planning a birthing centre or hospital birth) as evidence shows us that this is where we make the most progress. Draw the curtains, dim the lights, keep the house warm and cozy and keep things mellow. Have cuddles with your partner, try the bath or shower, watch a funny movie, bake!

Even if you’re not planning a home birth, it might be useful to have some waterproof plastic sheets and old towels and pillows ready to make a space for you to be in during this period. This can then be moved to another room if you want to change space, and can even go in the back of the car when it is time to go in. On a practical level, this will keep sofas and car seats clean! 13

1st Stage

• From 4cm to fully dilated (10cm)

• Contractions become strong and regular, lasting approx 40-60 secs

• Can last up to 12 hours for first babies / up to 6 hours for second or third babies

• The more ‘serious’ phase

• During this time the love hormone oxytocin and the body’s natural pain relief, endorphins keep increasing exponentially

The mood, environment, movements, breathing techniques and pain relief options that have helped you earlier on, are likely to continue to be helpful so keep doing whatever you have been doing.

Know that you can use the positioning of your body to help you cope with the intensity of what you may be feeling with the contractions as things progress.

For example, standing up or squatting in a very upright position is likely to make your contractions feel more intense, as it encourages your baby’s head down onto the cervix more powerfully. This may be helpful as it can make your contractions stronger and more effective, thus helping your cervix to dilate and helping to push your baby down and out. This is akin to ‘stepping on the gas’ to keep things moving along.

If that feels too much for you, try getting on all fours. This is like ‘cruising along at 30mph’; things are still progressing, but this position will help reduce some of the intensity you might be experiencing. In all fours we instantly feel more stable as we have four points of contact with the ground. This feeling of being more grounded gives a sense of security and safety. It also gives us more privacy; a birthing mother can look down at the floor and be in her own space, or even close her eyes here. Safety, stability, grounding, privacy - these are all positive feelings to encourage, helping increase the release of oxytocin in the body and therefore helping the contractions to keep coming. This is known as the “Positive Feedback Loop.”

If you still find things feel too strong for you when in all fours, try this: bend your arms, hands stacked, elbows out to the side and lean your head down onto your hands or the ground, while keeping your bottom up in the air. This is an antigravity movement for the baby, and is akin to ‘pressing the brakes’. It will give you a bit of a breathing space, make your contractions feel less intense and help you find your focus again. When you are ready to go for it again, come back up to all fours or upright, leaning forwards and continue.

So, remember:

• Upright: gravity, baby goes down, things move along.

• Or bottom up: things slow down, intensity lessens, gives you a rest.

• Or all fours: somewhere in between Try to remember this when you’re in labour, so you can use your positions to help you keep everything moving along smoothly and progressing, or tap on the brakes if you need to take a moment to rest and recharge. We can’t control how labour will unfold but these positions, combined with the birth breathing, can help us control our focus and increase our coping strategies for birth.

Other positions to try during this stage of labour:

STANDING – lean forwards against a wall, lean on a birth partner or dance with them, lean over the furniture. Or hold onto a rope or blanket attached to the ceiling, or over a door that you can then use to sink down from. Also walk, dance, rotate and rock the pelvis, have a shower.

SITTING - in partner’s lap, on the floor crossed-legged, on the toilet or the edge of the bed. Straddle the back of a chair so your back can be massaged while you lean forward. Sit on a chair and lean on kneeling partner, or sit on the birth ball.

SQUATTING - this can help open the pelvis, but it can also intensify the contractions and make them more powerful. Use during or in between contractions. Lean back against partner, a wall, sofa or cushion, or use a stool, the bottom step or a hospital bed to squat on with support (put pillows or blocks under the heels). Can be more effective to keep the tail bone tilting out and to keep your feet and knees parallel as this can open the pelvic inlet (rather than turning the toes out which can close it).

KNEELING - place pillows/blankets under knees and kneel into a beanbag, ball, partner, chair, bed. Be upright and lean forward, rotate your hips and move. Even kneel in bath while partner pours water over you. You can also try with one foot on the floor in a kneeling lunge and change sides regularly.

HANDS & KNEES - on all fours, use pillows or blankets to support the knees and bend your elbows to protect your wrists. You can lean on your forearms or while in all fours lean over a chair, sofa or bed, or even on someone else who is on all fours and have them rotate their hips or circle. Figure of 8 movements can be very hypnotic and help you clear your head especially if panicked thoughts start. Great to try if you have backache/posterior labour.

TO SLEEP - lie on left side, propped up. Beanbags or lots of cushions can help here.

Transition

• Usually this refers to the time between being fully dilated (at 10cms) and the baby’s head entering the birth canal (or vagina) although the emotional change can occur at any time during labour.

• Can last approx. 20-40 minutes. Contractions are regular and strong, with little or no rest in between - this is often when we ask for epidurals!

• Some women might go very quiet or cry, or feel like everything slows down or stops. Take the rest. Perhaps be aware that you might be in transition.

• Birth partners - may need to stay out of the way at this point, or alternatively follow ‘The Take Charge Routine’ (we’ll come to this!). You may notice erratic behaviour, or mum-to-be may express a desire to stop (i.e. “I can’t do this anymore”). If required, keep her working with her breath - suggest breathing together. Remind her how well she is doing and that she is going to see her baby soon. Use eye contact to reassure and give her a focus to ground her again. Eye contact also increase oxytocin, which may be useful at this time if she is panicking.

Things to do

• Stay with your Birth Breathing as much as you can – this will help you stay calm. If you are getting tired, really focus on getting that in breath down into the belly. Take resting positions.

• Go with your body and let your body do this.

• Think: “I am calm and my baby is calm” / “Every moment I am getting closer to meeting you - we’re nearly there”

2nd Stage

• Fully dilated (10cms) to delivery of the baby

• Contractions are regular, but there are longer rest periods; make the most of these. Use ‘The Big Sigh’ breathing to relax and doze off. Think and feel the word ‘relax’ as you exhale. Soften your jaw to release the birthing muscles.

• A feeling of pressure in the bowels (similar to when you need a poo), signalling that your baby has descended into the vagina and is on its way out.

• Crowning and then delivery of your baby

Things to do

• Take your time, do not feel rushed between pushes - keep using Golden Thread (Long Exhalation) breath

• Birth partner could sponge your face and neck. Have sips of water, use the toilet / bedpan.

• Crowning - this is a stingy sensation - only lasts a few seconds as the baby’s head is delivered - the slower your baby’s head is born, the less likely you are to tear (also prepare the area with perineal massage up to 8 weeks prior to the due date). Feel your baby’s head as it crowns – it’s amazing!

Remember LOOSE MOUTH = LOOSE VAGINA. And by that we mean, SMILE! This will help relax your jaw which in turn releases the muscles down below.

Once your baby crowns aim to breathe your baby out, rather than push (if possible - this may be impossible, if your body just takes over). When you breathe now, close your mouth and draw your chin down to your chest, send your breath down and out of your vagina. Use this j-breathing to push if you need to. Follow your midwife’s suggestions - she will guide you here. She may ask you to pant and not push if you need a bit more time for your perineum to open. Trust your body and your midwife.

Positions for Delivery:

• Upright positions assist gravity in pushing the baby down.

• Squatting opens the pelvis up to 28-30%. Supported squatting is more comfortable - lean on someone / wall / furniture. Move hips. Keep your tail bone tilting outwards and feet parallel (i.e. don't put your toes out).

• Kneeling - all fours / half kneel with one leg up (out to side). Sway pelvis gently side to side. Change leg position. Facilitates optimal positioning.

• Sitting - anywhere as per the pictures

• Avoid lying down on your back as this can compress the sacrum, when you need to give it the space to move back and out. Try to keep this area free as much as possible.

NOTE: depending on your baby’s positioning there are a few occasions when your midwife may suggest lying flat on your back as it can help open your pelvis in another way. So do listen to your midwife and be guided by their suggestions on positions as well.

• Change positions often if you feel stuck.

• Recline - useful if exhausted, or your legs are tired and feel a bit wobbly. Try lying down on your left side, so you can easily lift your right knee up to your armpit and make lots of space for birthing your baby.

• If you have SPD - all fours and left side reclining are the best positions to use. Remember to use some ribbon to find your ‘pain free gap’ and if you need to have your feet in stirrups, make sure the midwife moves both legs in at the same time and that she knows you have SPD.

*Perineal Massage: Massaging the perineum with a carrier oil or olive oil can help stretch it and reduce tearing, or the need for an episiotomy. There is plenty of information about this online, with instructions on how to do it. Have a look and decide if it’s for you. Suitable from about 32/34 weeks.

A water birth

If you are considering a water birth, it is useful to know that you can get in the bath or shower at any time throughout labour and water therapy is a fantastic way to relax and help you with the contractions. It is also recommended if you decide to get in the pool, to save this until you are around 7/8cm dilated and that you stay in for up to 1.5-2hours max. This is because evidence shows that staying in for longer can actually slow things down too much. You can use the pool just for comfort and get out to have your baby. Or you can stay in to have your baby.

If you have been induced you will need to be monitored so it is much more unlikely you will have a water birth.

As you are in water, the positioning of your body is less important - you can lean forward over the sides or lean back again the sides.

As your baby’s head is born, it is best not to over touch them, as this may stimulate them to try to breath. Midwifes will be more hands off as well. Once the baby is born, remember is it still connected you via the umbilical cord. Careful you (or your midwife) will help you bring the baby slowly and gently out of the water onto your chest. One your baby has take its first breath of air, do not re-submerge your baby into the water.

Tips for a long and/or posterior labour

• Alternate between stimulating labour and getting things moving, and resting to conserve your energy levels

• Lean forward a lot (in between and during surges) and rotate hips - get into all fours positions (i.e. scrubbing the floor movements / pelvic rocking / leaning over or sitting on a birth ball)

• Be patient, distract yourself with movies, music, sleeping

• Use hot towels to ease back ache

• Taking a bath or shower can help ease discomfort

• Massage the sacrum or the back and shoulders

• Try acupuncture or acupressure points, homeopathy or aromatherapy

• Think positively - “I am calm and my baby is calm” / “Every moment I am getting closer to meeting you - we’re nearly there” / “My baby is coming.”

• Birth partners - lots of love and support is needed. Ask her if anything is weighing heavily in her heart - an unexpressed fear, or other emotions can hold up labour. Help her let go. Consider changing the environment, the people with her, the music, lighting. If she is able suggest going for a walk or taking a hot bath.

Assisted Birth

The baby may need assistance to be delivered vaginally for a number of reasons, including when the birthing woman gets too tired, the baby is presenting in a more tricky position, or they are in distress. In these circumstances, the use of ventouse or forceps, or having a caesarean might be suggested by the doctor.

Forceps - these are used when the baby is higher up in the birth canal. They are rather like metal salad spoons which are inserted into the vaginal one at a time and cradle the baby’s head. When mum has a contraction the doctor can use the forceps to rotate the baby into a better position and facilitate the delivery. They can also help prevent the ‘slide back’ of the baby into the birth canal.

Ventouse - used when the baby is nearer the entrance of the vagina. It is a little suction cap that goes onto the baby’s head - again to help rotate the baby and prevent ‘slide back’. As with forceps, this is only used with maternal effort during a contraction.

▪ Caesarean - if the baby is unable to be delivered vaginally, the obstetrician will perform an operation under local (spinal) or general anaesthetic, and baby is delivered through the tummy (usually along the knicker line). If you do have a caesarean, consider requesting a vaginal swab to ensure your baby receives the same vaginal microbes it will need to help with immune system blueprinting. For more information about caesareans we recommend watching the documentary Microbirth (http://microbirth.com/).

Remember, everything has its place and you can decide yes or no to any of the above. If forceps or ventouse is suggested see if you can use cafetiere Pelvic Floor holds to also help prevent ‘slide back’ - this is where we exhale as we push and bear down, then on the inhale we hold the pelvic floor muscles with effort, then exhale and bear down again. This encourages the baby down without slide back - rather like the plunger on a coffee cafetiere.

3rd Stage

Delivery of the placenta and the membranes The baby may be here, but mum is very much still in the birthing process. The delivery of the placenta is an important part of the birth, hence why it is called the ‘third stage’ of labour.

Birthing partners are still needed and everyone needs to respect this part of the process. There will be time to make phone calls announcing the arrival of the baby later! During this time it’s important to maintain a quiet, calm and loving space – as it is also your baby’s first moments in the world!!

Delayed Cord Clamping, or The Golden Minute – During the first 2-3 minutes immediately after birth babies are still receiving vital oxygen and the iron they need for growth from the placenta, via the umbilical cord. So it is very important to leave the cord unclamped for around this length of time, or until it has finished pulsating. This ensures that the remaining 1/3 of the baby’s blood which resides in the placenta and cord has the time to transition into the baby. Even though this is now common practice, you can still include this on your Birth Wish List or Intentions.

There are two ways for the placenta to be delivered:

Physiological - meaning let nature take its course. Gentle contractions will continue and the placenta detaches and comes away. Usually this is expected to take up to 1 hour, but can take two. No drugs are given. Umbilical cord can be left attached to baby and the mother births the placenta with uterine contractions and gentle pushing. Or the cord once it has finished pulsating, can be clamped and cut and the mother births the placenta with uterine contractions and gentle pushing.

Active Management – A dose of artificial oxytocin called ‘syntocinon’ is given via an intra-muscular injection into the mother’s thigh. This causes the uterus to contract again and the placenta to be expelled, aided by the midwife gently drawing on the cord. This process can take up to 30 minutes, although it’s usually much faster - often taking between 5-10mins. Please note, in some cases the injection may cause nausea or vomiting for mum, although an anti-sickness drug can also be given.

This is something to decide at the time. If you have had any interventions during labour and delivery then you would be advised to continue with Active Management. However if everything has progressed physiologically smoothly, with no interventions, then you may wish to complete the process that way.

What happens to the placenta?

This incredible organ has sustained your baby’s life throughout pregnancy. And although your body has now shed it, the placenta is still full of nutrients and hormones which many people believe can still have great benefits for both mother and baby.

And so there are several options as to what you can do with your placenta post-partum:

• The hospital or midwife can take it away and dispose of it for you.

• It can be consumed; either raw in a smoothie, or dried and encapsulated into tablets for mum to take postnatally. Some anecdotal evidence suggests ingesting it can aid milk flow, increase energy levels, improve mood and reduce occurrences of postnatal depression (PND) - thorough studies are currently underway to determine this. It should be noted that there is also an argument that because the placenta is a filter organ which also filters viruses and bacteria away from the baby, it shouldn’t be ingested.

• It can be used to create a homeopathic health remedy or tincture for your child. Plenty of companies offer this service, and there are also ways you can do this yourself at home - have a look on YouTube.

• Some people decide they wish to bury it under a tree.

• You may consider Cord Blood Donation or Cord Blood Stem Cell Storage. Research is on-going about the remarkable stem cells found in the cord, and the potential for future use. You can donate cord blood or cells to this research, or alternatively have your child’s stem cells collected and stored for their own future use.