What stages will I go through during labor and birth?

The process of labor and birth is divided into three stages.

The first stage begins with the onset of contractions that cause progressive changes in your cervix and ends when your cervix is fully dilated. This stage is divided into two phases: early (or latent) and active labor.

During early labor, your cervix gradually effaces (thins out) and dilates (opens). That's followed by active labor, when your cervix begins to dilate more rapidly and contractions are longer, stronger, and closer together. People often refer to the last part of active labor as transition.

The second stage of labor begins once you're fully dilated and ends with the birth of your baby. This is sometimes referred to as the pushing stage.

The third and final stage begins right after the birth of your baby and ends with the separation and subsequent delivery of the placenta.

Every pregnancy is different, and there's wide variation in the length of labor. For first-time moms who are at least 37 weeks along, labor often takes between ten and 20 hours. For some women, though, it lasts much longer, while for others it's over much sooner. Labor generally progresses more quickly for women who've already given birth vaginally.

First stage: Early labor

Once your contractions are coming at relatively regular intervals and your cervix begins to progressively dilate and efface, you're officially in early labor. But unless your labor starts suddenly and you go from no contractions to fairly regular contractions right away, it can be tricky to determine exactly when true labor starts. That's because early labor contractions are sometimes hard to distinguish from the inefficient Braxton Hicks contractions that may immediately precede them and contribute to so-called false labor.

If you're not yet at 37 weeks and you're noticing contractions or other signs of labor, call your caregiver immediately so she can determine whether you're in preterm labor.

During early labor, your contractions will gradually become longer, stronger, and closer together. While the experience of labor varies widely, it might start with contractions coming every ten minutes and lasting 30 seconds each.

Eventually they'll be coming every five minutes and lasting 40 to 60 seconds each as you reach the end of early labor. Some women have much more frequent contractions during this phase, but the contractions will still tend to be mild and last less than a minute.

Sometimes early labor contractions are quite painful, even though they may be dilating your cervix much more slowly than you'd like. If your labor is typical, however, your early contractions won't require the same attention that later ones will.

You'll probably be able to talk through them and putter around the house. You may even feel like taking a short walk. If you feel like relaxing instead, take a warm bath, watch a video, or doze off between contractions if you can.

You may notice an increase in mucusy vaginal discharge, which may be tinged with blood — the so-called bloody show. This is perfectly normal, but if you see more than a tinge of blood, be sure to call your caregiver. Also call if your water breaks, even if you're not having contractions yet.

Otherwise, if you're at least 37 weeks along and your caregiver hasn't advised you differently, expect to sit out early labor at home. (When to call your midwife or doctor and when she's likely to have you go to the hospital or birth center are things to discuss ahead of time at your prenatal visits.)

Early labor ends when your cervix is about 4 centimeters dilated and your progress starts to accelerate.

How long early labor lasts
It can be difficult to tell exactly when early labor starts, so it's often not easy to say how long this phase typically lasts — or even, after the fact, how long it lasted for a particular woman. The length of early labor is quite variable and depends in large part on how ripe your cervix is at the beginning of labor and how frequent and strong your contractions are.

With a first baby, if your cervix isn't effaced or dilated to begin with, this phase may take about six to 12 hours, although it can be longer or significantly shorter. If your cervix is already very ripe or this isn't your first baby, it's likely to go much more quickly.

Coping tips
Don't become a slave to your stopwatch just yet — it's stressful and exhausting to record every contraction over the many long hours of labor, and it isn't necessary. Instead, you may want to time them periodically to get a sense of what's going on. In most cases, your contractions will let you know in no uncertain terms when it's time to take them more seriously.

Meanwhile, it's important to do your best to stay rested, since you may have a long day (or night) ahead of you. If you're tired, try to nap between contractions.

Be sure to drink plenty of fluids so you stay well hydrated. And don't forget to urinate often, even if you don't feel the urge. A full bladder may make it more difficult for your uterus to contract efficiently, and an empty bladder leaves more room for your baby to descend.

If you're feeling anxious, you may want to try some relaxation exercises or do something to distract yourself a bit — like watching a movie or reading a book.

First stage: Active labor

Active labor is when things really get rolling. Your contractions become more frequent, longer, and stronger, and your cervix begins dilating more quickly, going from about 4 to 10 centimeters. (The last part of active labor, when the cervix dilates from 8 to 10 centimeters, is called transition, which is described separately in the next section.)

In contrast to early labor, you'll no longer be able to talk through the contractions. Toward the end of active labor your baby may begin to descend, although he might have started to descend earlier or he might not start until the next stage.

As a general rule, once you've had regular, painful contractions (each lasting about 60 seconds) every five minutes for an hour, it's time to call your midwife or doctor and head to the hospital or birth center. Some prefer a call sooner, so clarify this with your caregiver ahead of time.

In most cases, the frequency of contractions eventually increases to every two and a half to three minutes, although some women never have them more often than every five minutes, even during transition.

How long active labor lasts
On average, it takes about four to eight hours for a woman having her first baby to go from 4 centimeters to full dilation. That's if she's not being given oxytocin (Pitocin) or doesn't have an epidural. Pitocin generally speeds up the active phase, while epidurals tend to make it last longer.

If you've already had a vaginal birth, active labor is likely to go much more quickly.

Coping tips
Many of the pain-management and relaxation techniques used in natural childbirth — such as breathing exercises and visualization — may help you during labor, whether or not you're planning on receiving medication. A good labor coach can be a huge help now, too. And you'll probably appreciate lots of gentle encouragement.

It may feel good to walk, but you'll probably want to stop and lean against something (or someone) during each contraction. You should be able to move freely around the room after your caregiver evaluates you, as long as there are no complications.

If you're tired, try sitting in a rocking chair or lying in bed on your left side. This might be a good time to ask your partner for a massage. Or, if you have access to a tub and your water hasn't broken, you can take a warm shower or bath.

If you've already decided you want pain medication or you're having a hard time coping with contractions and nothing else seems to help, now's the time to talk to your provider about getting an epidural or systemic medication.

Transition

The last part of active labor — when your cervix dilates from 8 to a full 10 centimeters — is called the transition period because it marks the shift to the second stage of labor. This is the most intense part of labor. Contractions are usually very strong, coming every two and a half to three minutes or so and lasting a minute or more, and you may start shaking and shivering.

By the time your cervix is fully dilated and transition is over, your baby has usually descended somewhat into your pelvis. This is when you might begin to feel rectal pressure, as if you have to move your bowels. Some women begin to bear down spontaneously — to "push" — and may even start making deep grunting sounds at this point.

There's often a lot of bloody discharge. You may also feel nauseated or even vomit now.

Some babies, however, descend earlier and the mom feels the urge to push before she's fully dilated. And others don't descend significantly until later, in which case the mom may reach full dilation without feeling any rectal pressure. It's different for every woman and with every birth.

If you've had an epidural, the pressure you'll feel will depend on the type and amount of medication you're getting and how low the baby is in your pelvis. If you'd like to be a more active participant in the pushing stage, ask to have your epidural dose lowered at the end of transition.

How long transition takes
Transition can last anywhere from a few minutes to a few hours. It's much more likely to be fast if you've already had a vaginal delivery.

Coping tips
If you're laboring without an epidural, this is when you may begin to lose faith in your ability to handle the pain, so you'll need lots of extra encouragement and support from those around you.

Some women appreciate light touch (effleurage), some prefer a stronger touch, and others don't want to be touched at all. Sometimes a change of position provides some relief — for example, if you're feeling a lot of pressure in your lower back, getting on all fours may reduce the discomfort. A cool cloth on your forehead or a cold pack on your back may feel good, or you may find a warm compress more comforting.

On the other hand, because transition can take all of your concentration, you may want all distractions — music or conversation or even that cool cloth or your partner's loving touch — eliminated.

It may be useful to focus on the fact that those hard contractions are helping your baby make the journey out into the world. Try visualizing his movement down with each contraction.

The good news is that if you've made it this far without medication, you can usually be coached through transition — one contraction at a time — with constant reminders that you're doing a great job and that the end is near.

Second stage: Pushing

Once your cervix is fully dilated, the work of the second stage of labor begins: the final descent and birth of your baby. At the beginning of the second stage, your contractions may be a little further apart, giving you the chance for a much-needed rest between them.

Many women find their contractions in the second stage easier to handle than the contractions in active labor because bearing down offers some relief. Others don't like the sensation of pushing.

If your baby's very low in your pelvis, you may feel an involuntary urge to push early in the second stage (and sometimes even before). But if your baby's still relatively high, you probably won't have this sensation right away.

As your uterus contracts, it exerts pressure on your baby, moving him down the birth canal. So if everything's going well, you might want to take it slowly and let your uterus do the work until you feel the urge to push. Waiting a while may leave you less exhausted and frustrated in the end.

However, in many hospitals it's still routine practice to coach women to push with each contraction in an effort to speed up the baby's descent — so let your caregiver know if you'd prefer to wait until you feel a spontaneous urge to bear down.

If you have an epidural, the loss of sensation can blunt the urge to push, so you may not feel it until your baby's head has descended quite a bit. Patience often works wonders. In some cases, though, you'll eventually need explicit directions to help you push effectively.

Your baby's descent may be rapid or, especially if this is your first, gradual. With each contraction, the force of your uterus — combined with the force of your abdominal muscles if you're actively pushing — exerts pressure on your baby to continue to move down through the birth canal. When a contraction is over and your uterus is relaxed, your baby's head will recede slightly in a "two steps forward, one step back" kind of progression.

Try different positions for pushing until you find one that feels right and is effective for you. It's not unusual to use a variety of positions during the second stage.

After a time, your perineum (the tissue between your vagina and rectum) will begin to bulge with each push, and before long your baby's scalp will become visible — a very exciting moment and a sign that the end is in sight. You can ask for a mirror to get that first glimpse of your baby, or you may simply want to reach down and touch the top of his head.

Now the urge to push becomes even more compelling. With each contraction, more and more of your baby's head becomes visible. The pressure of his head on your perineum feels very intense, and you may notice a strong burning or stinging sensation as your tissue begins to stretch.

At some point, your caregiver may ask you to push more gently or to stop pushing altogether so your baby's head has a chance to gradually stretch out your vaginal opening and perineum. A slow, controlled delivery can help keep your perineum from tearing. By now, the urge to push may be so overwhelming that you'll be coached to blow or pant during contractions to help counter it.

Your baby's head continues to advance with each push until it "crowns" — the time when the widest part of his head is finally visible. The excitement in the room will grow as your baby's face begins to appear: his forehead, his nose, his mouth, and, finally, his chin.

After your baby's head emerges, your doctor or midwife will suction his mouth and nose and feel around his neck for the umbilical cord. (No need to worry. If the cord is around his neck, your caregiver will either slip it over his head or, if need be, clamp and cut it.)

His head then turns to the side as his shoulders rotate inside your pelvis to get into position for their exit. With the next contraction, you'll be coached to push as his shoulders emerge, one at a time, followed by his body.

Once your baby hits the atmosphere, he needs to be kept warm and will be dried off with a towel. Your doctor or midwife may quickly suction your baby's mouth and nasal passages again if he seems to have a lot of mucus.

If there are no complications, he'll be lifted onto your bare belly so you can touch, kiss, and simply marvel at him. The skin-to-skin contact will keep your baby nice and toasty, and he'll be covered with a warm blanket — and perhaps given his first hat — to prevent heat loss.

Your caregiver will clamp the umbilical cord in two places and then cut between the two clamps — or your partner can do the honors.

You may feel a wide range of emotions now: euphoria, awe, pride, disbelief, excitement (to name but a few), and, of course, intense relief that it's all over. Exhausted as you may be, you'll also probably feel a burst of energy, and any thoughts of sleep will vanish for the time being.

How long the second stage lasts
The entire second stage can last anywhere from a few minutes to several hours. Without an epidural, the average duration is close to an hour for a first-timer and about 20 minutes if you've had a previous vaginal delivery. If you have an epidural, the second stage generally lasts longer.

Third stage: Delivering the placenta

Minutes after giving birth, your uterus begins to contract again. The first few contractions usually separate the placenta from your uterine wall. When your caregiver sees signs of separation, she may ask you to gently push to help expel the placenta. This is usually one short push that's not at all difficult or painful.

How long the third stage lasts
On average, the third stage of labor takes about five to ten minutes.

And then what?
After you deliver the placenta, your uterus should contract and get very firm. You'll be able to feel the top of it in your belly, around the level of your navel.

Your caregiver, and later your nurse, will periodically check to see that your uterus remains firm, and massage it if it isn't. This is important because the contraction of the uterus helps cut off and collapse the open blood vessels at the site where the placenta was attached. If your uterus doesn't contract properly, you'll continue to bleed profusely from those vessels.

If you're planning to breastfeed, you can do so now if you and your baby are both willing. Not all babies are eager to nurse in the minutes after birth, but try holding your baby's lips close to your breast for a little while. Most babies will eventually begin to nurse in the first hour or so after birth if given the chance.

Early nursing is good for your baby and can be deeply satisfying for you. What's more, nursing triggers the release of oxytocin, the same hormone that causes contractions, which helps your uterus stay firm and well contracted.

If you're not going to nurse or your uterus isn't firm, you'll be given oxytocin to help it contract. (Some providers routinely give it to all women at this point). If you're bleeding excessively, you'll be treated for that as well.

Your contractions at this point are relatively mild. By now your focus has shifted to your baby, and you may be oblivious to everything else going on around you. If this is your first baby, you may feel only a few contractions after you've delivered the placenta. If you've had a baby before, you may continue to feel occasional contractions for the next day or two.

These so-called afterbirth pains can feel like strong menstrual cramps. If they bother you, ask for pain medication. You may also have the chills or feel very shaky. This is perfectly normal and won't last long. Don't hesitate to ask for a warm blanket if you need one.

Your caregiver will examine the placenta to make sure it's all there. Then she'll check you thoroughly to spot any tears that need to be stitched.

If you tore or had an episiotomy, you'll get an injection of a local anesthetic before being sutured. You may want to hold your newborn while you're getting stitches — it can be a great distraction. If you're feeling too shaky, ask your partner to sit by your side and hold your new arrival while you look at him.

If you had an epidural, an anesthesiologist or nurse anesthetist will come by and remove the catheter from your back. This takes just a second and doesn't hurt.

Unless your baby needs special care, be sure to insist on some quiet time together. The eyedrops and vitamin K can wait a little while. You and your partner will want to share this special time with each other as you get acquainted with your new baby and revel in the miracle of his birth.

Fertility treatment found to make pregnancy less likely

LITTLE Jensen Jance is by all accounts the perfect baby. At two weeks old, his mother reports he eats efficiently, settles well and is even allowing her some sleep.

Then again, it is possible that after five years of waiting for the child they desperately wanted, Guilia and Michael Jance are unusually positive new parents.

After tests did not reveal a reason why they could not conceive, they were offered Clomid, a hormone tablet that doctors thought corrected subtle problems with ovulation. But after three-month courses on two separate occasions, there was still no pregnancy.

That occurred only after the Sydney couple was referred for insemination directly into 39-year-old Mrs Jance's uterus using a specially prepared sperm sample from her husband, together with an injected hormone to super-charge the release of eggs.

"It feels fantastic," a besotted Mrs Jance said this week of finally being a mother. "It's just incredible to see him here. We can't stop looking at him."

The Jances' journey is in line with new results from British research that concluded Clomid was useless or worse for couples whose failure to conceive was unexplained, and that such people should move straight to in-vitro fertilisation (IVF) or other more high-tech methods.

The study, from five hospitals in Scotland, followed 580 couples who were randomly assigned either to receive no treatment beyond advice about the timing of intercourse, a course of Clomid, or the intrauterine insemination IUI) that finally helped the Jances, but without the ovary-stimulating injection.

Research leader Allan Templeton — the architect of Britain's fertility treatment policy, which requires couples to try low-tech methods before they can get access to publicly-funded IVF — found the IUI technique only slightly improved the chances of having a baby. Clomid actually seemed to reduce the chance of success.

The results — considered definitive because of the strong design of the study and the large number of participants — "challenge current practice", Professor Templeton wrote yesterday in medical journal BMJ.

Michael Chapman, the fertility specialist who treated the Jances, said about one-third of patients with unexplained infertility could achieve pregnancy with IUI provided they also received ovarian stimulation. The British work confirmed his own observation that, "unstimulated IUI is a waste of time," he said.

Professor Chapman, who is medical director of private clinic group IVF Australia, said the technique was a "stepping stone" for the majority of couples who would eventually need IVF, but it had the advantage of being less invasive. Clomid worked well for women with polycystic ovarian syndrome, a condition that suppresses ovulation, Professor Chapman said. But it was also widely prescribed for unexplained infertility, often by gynaecologists who could not offer patients IVF.

Mark Bowman, medical director of Sydney IVF, said he preferred to move straight to IVF after a couple had waited adequate time to conceive spontaneously. Insemination combined with ovary stimulation, "is almost as invasive as IVF but there is a much higher multiple pregnancy rate," which often meant health problems for the resulting twins and triplets, he said.

Pre-pregnancy diabetes tied to more birth defects

ATLANTA (AP) — Diabetic women who get pregnant are three to four times more likely to have a child with birth defects than other women, according to new government research.
The study is the largest of its kind, and provides the most detailed information to date on types of birth defects that befall the infants of diabetic mothers, including heart defects, missing kidneys and spine deformities.

The study lists nearly 40 types of birth defects found to be significantly more common in the infants of diabetic mothers than in those who weren't diabetic or who were diagnosed with diabetes after they became pregnant.

The study's list of diabetes-associated birth defects is surprising — it's much longer than was previously understood, said Janis Biermann, senior vice president for education and health promotion at the March of Dimes.

"It adds more information about the specific types of birth defects associated with pregestational diabetes and gestational diabetes," said Biermann, who was not involved in the research.
Researchers from the Centers for Disease Control and Prevention led the study, which is being published in the American Journal of Obstetrics and Gynecology. CDC officials released the study Wednesday.

Birth defects affect one in 33 babies born in the United States, and cause about one in five infant deaths. The cause of most birth defects isn't known but some risk factors include obesity, alcohol, smoking and infections.

Doctors have known for decades about the threat diabetes poses to pregnancies. Past research has focused on dangers to the infant by the extra amounts of glucose — sugar — circulating in the womb of a diabetic mother. Studies with rats and mice clearly show excess sugar harms fetal tissue development, said Dr. E. Albert Reece, a study co-author and dean of the University of Maryland School of Medicine, who directs birth defects research there.

The new study draws from the birth records between 1997 and 2003 at hospitals in 10 states — Arkansas, California, Georgia, Iowa, Massachusetts, New Jersey, New York, North Carolina, Texas and Utah.

The study focused on the 13,000 births involving a major birth defect, and compared them to nearly 5,000 randomly selected healthy births from the same locations.

Mothers were asked if they had been diagnosed with diabetes before or during their pregnancy. The researchers said those who were diagnosed while pregnant either had a temporary, pregnancy-induced condition called gestational diabetes or had diabetes that had gone undiagnosed until they were pregnant.

The study found that there was no diabetes involved in 93 percent of the birth defects.
About 2 percent of the children with single birth defects were born to mothers who had diabetes before they became pregnant. About 5 percent of the infants with multiple defects were born to mothers with that condition. In healthy births, the percentage of mothers who were diabetic before pregnancy was much lower.

The study also showed a wide range of birth defects that included malformation of the heart, spine, limbs and gastrointestinal tract.

"Diabetes is not discriminating" in which birth defects it's linked to, said Dr. Adolfo Correa, a CDC epidemiologist who was the study's lead author.