How Birth Works

Listen to any group of women telling their birth stories and it is very easy to see why it can be so difficult to accurately describe labour to a first time mother.  Even second time mothers are surprised by how different labours can be. Yet there is often an urgent desire in pregnancy to know how it might be. The birth stories on this website are here to support, inspire and inform you but your own birth story will be just that, your own story with its own beginning and ending and its very own unique pattern. First of all though it might help to understand how the process should work.

In this country many of us grow up knowing and believing that birth is dangerous, enormously painful and best done with lots of pain relief and technology. Actually, it shouldn’t be. Think about it. Why would we be designed to give birth in enormous pain and terror? What other mammal needs almost 50 per cent of its offspring born by caesarean or vacuum extraction or forceps without improvement in mortality rates? These things are good and proper things to happen where babies or mothers are truly at risk but what if by our very concern we are causing many of the problems we are trying to eliminate?

“There is a secret in our culture, it’s not that birth is painful it is that women are strong.”
— Khaltouma, midwife, Sudan

Vast amounts of research have been done on birth, although many studies have been poorly done and their results interpreted to fit the researcher’s bias. Yet there is good solid research to show that there are some really simple things that women and their partners can do to help themselves to a straightforward birth.

Labour begins

As pregnancy draws to an end, between 37 and 42 weeks, the cervix, the entrance to the womb, starts to soften and to move forward. Your body is producing hormones which relax the bones of your pelvis and allow them to get bigger. As the baby engages into the pelvis you may notice that your bump appears lower and you are aware of pressure in your pelvis. If this is your second pregnancy your baby may not engage until labour starts.

The womb starts to produce another hormone (prostaglandin) which begins to produce very mild cramping in the muscles of the womb or backache which can feel like period pain. Some women, but not all, experience Braxton Hicks contractions which are sometimes called practice contractions. They are usually painless but some women can find them very uncomfortable – whether you have Braxton Hicks or not, whether they are painful or not does not seem to have any impact on your labour.

The hormonal changes in your body can make you euphoric or weepy, either is completely normal. Some women get a burst of energy and want to clean things, sometimes called nesting. Others don’t feel any differently at all. Some women are very restless in late pregnancy or feel unusually worried about leaving home.

It is normal for the vagina to produce more mucous discharge. Some women notice that they lose a little weight in the week before labour begins and some have slight diarrhoea. In a very few labours the waters can break or can be trickling without any other signs of labour. If you think your waters might be leaking or you know they have, do contact the maternity unit as it is usually a good idea to have baby’s position checked. Some hospitals have a policy of offering induction 24 hours after the waters have broken in a mother who is at full term (37 weeks onwards). See our article on induction for more information. Only 10% of labours actually begin with the waters breaking but thanks to t.v. dramas many people think this happens more often than it does!

As the cervix softens you may notice jelly like mucous coming from your vagina when you go to the toilet. Not everyone sees this as sometimes the body just absorbs it but it is called “having a show” and means that your body is getting ready to labour. It could be days however before anything else happens. The show can sometimes be greenish, especially if the baby is past 40 weeks, and it can be pink or blood streaked. Providing that you are not seeing fresh blood of more than 50p coin size, you do not need to inform your midwife but if you are worried about anything you can ring your community midwife or the maternity unit at your hospital.

Labour Begins – Early or Pre-Labour

The womb is a muscle and by the end of pregnancy it will be the biggest muscle in your body. The hormones produced by your body tell the muscle to shorten and this shortening is called a contraction. Between contractions the muscle relaxes again but it stays slightly shorter with each contraction. This shortening action pulls on the neck of the womb, the cervix, to make it thinner, this is called effacing, and then to open very slowly, which is called dilating. It can take 10 to 12 hours or more for a first time mother’s cervix to dilate to 4cm which is when the medical profession will say you are in established labour. So this early or pre-labour can be a long time which you have to manage on your own.

Contractions often start out quite weakly at first and gradually get longer, stronger and closer together. Women describe them in all sorts of different ways, as a cramping, hardening, pulling or tightening. Some women feel their early contractions as backache or as a cramping feeling in their thighs. Between the early contractions there will usually be no sensation at all and they may be 20 or more minutes apart.

Sometimes early labour contractions stop for a few hours before starting again, or are frequent and niggly but not really moving on from that. Some women sleep through early labour contractions and wake up to find contractions coming strongly and with little gap in between. What most labours have in common is that the contractions get longer and stronger so that they require concentration and you can’t talk through them and so that you need to rest in between them. When that is happening you know that labour has really begun.

“I went to bed thinking that this baby was never going to come and feeling completely fed-up. During the night I woke once or twice with strong period-like cramps but I was so convinced I would never labour I just rolled over and ignored them -I told my body it could wake me up when things got serious! Just after six am I got up to use the loo and felt my first really strong contraction which stopped me in my tracks. I was more excited than frightened – woohoo, baby was coming at last”
— Elaine, 42, Sussex

What helps?

This part of labour can be quite unpredictable – it helps not to get too excited and not to use up too much energy, you could have a long, long journey ahead. If labour is a marathon, this bit can be the journey to the start line or the first 5 miles if you prefer, you are very keen but need to not exhaust yourself before the going gets tough. If it is night-time go to bed, if its daytime try to distract yourself but do things you will find relaxing.

If you have been having niggling, on/off contractions for quite a while and want to kick them on a bit you could try a walk but keep it local, a cross country hike is probably not a good idea. Gentle sex has been known to move labour on a bit – orgasm makes us produce the hormone oxytocin that makes labour work. If that doesn’t appeal, just lots of cuddles, perhaps a massage can help to relax you – tense, anxious women often don’t labour well as when we release adreniline it slows down the release of labour hormones.

Continue to eat and drink during this phase so long as you are not being sick. It helps to give you energy for later and prevent you from becoming dehydrated. 

Established or Active Labour

Once your cervix has dilated to about 4cm, the contractions tend to get stronger and longer and even closer together. They may last 40 seconds or more and be coming ever 5 minutes or so. Unless you have trained yourself in self-examination it can be very hard to tell how dilated you are so its important to tune into how you are feeling.

It is likely that you are in established labour if:

  • Your contractions are very strong, very regular and have been increasing in pace and strength over several hours.
  • You have to stop and deal with your contractions, you can’t talk through them
  • You are making noise during a contraction
  • You want to rest between contractions

If you are in doubt or worried about what is happening ring the maternity unit and talk it through with them. Once you feel you are in established labour it is time to call your midwife out for a homebirth or to go to your chosen place of birth. Always let your maternity unit know that you are coming in, it helps them to get staffing sorted out and to manage their birthing rooms.

If labour slows down or is not progressing well, try moving about, going for a walk, have something to eat and drink and do things that will help you to relax – sometimes going somewhere dark and quiet, having a bath or having a private kiss and cuddle with your partner can help. Try and think through if something is bothering you that might be hindering your labour – are you getting on OK with the midwife, is there a smell or something else which is bugging you, are you really worried about something and need some reassurance?

Changing the environment, changing your carer if you are not getting along can sometimes make a huge difference. You have every right to say that you want someone else as your midwife, your partner could go and have a quick chat with the senior midwife on duty you don’t have to tell someone to their face that you don’t like them. It is fairly normal for labour contractions to slow down a bit if you go to hospital or even sometimes when the midwife arrives at a homebirth, don’t panic just give yourself time to settle down again and refocus on your coping tactics.

What Helps?

Position and Movement

Being upright and mobile in labour has been proven to reduce pain and make labour quicker. If you want to read the evidence on this have a look at www.infochoice.org.uk which has free evidence based leaflets for you to download.

Most women feel instinctively that they want to be upright as contractions are much easier to cope with. Many women rock and sway through a contraction whilst standing and leaning against a wall, or holding onto the back of a chair. As labour progresses, they might move on to kneeling and leaning on a birth ball or a chair or a beanbag. The position that you are looking for, and tell your partner and carers to check for, is one in which you feel most comfortable and that holds your pelvis upright, forward and open (UFO)

Being upright reduces pain and uses gravity to help the baby’s head to press on your cervix, this in turn tells your body to release more labour hormone and keeps labour going. The womb tilts naturally forward as it contracts and by forward leaning you help it to work efficiently and less painfully. If your pelvis is open it allows the baby to move down into a good position ready for the pushing stage later on. By rocking and swaying you are also making room for the baby and it helps a lot with coping with the strength of the contractions.

Women very, very rarely lie down on a bed in labour but we are sometimes culturally conditioned to do so – if all you have ever seen or imagined is women lying down and suffering you are much more likely to think that is what you should do, particularly if you have a birthing environment with only a bed in it. Lying down tends to make labour much more painful as the weight of the uterus presses down on your spine and increases the pain message going up through your spinal column to your brain. You could:

  • Take the mattress of the floor and go on all fours
  • Stand up and lean on the bed
  • Kneel on the bed,, pile up a bank of cushions against the headboard and lean forward into them.
  • If you are getting very tired try sitting the wrong way round on a chair with some cushions to lean onto, or
  • Sit on a birthing ball and lean onto a piece of furniture.
  • If you feel you absolutely must lie down, lie on your side but do try exploring other positions first.

The National Childbirth Trust produces a great leaflet on positions for labour and birth and you can get one from www.nctsales.co.uk.

What Can Birth Partners Do?

There is lots of research showing that women relax more if they have someone they know with them in labour. This might be your partner, or you might want to take mum, another relative or a friend either as well as or instead of your partner. Having a female companion as well as your partner has been shown to lower pain and speed up labour. You might also consider a Doula. Ideally your midwife should be someone you know and who is with you throughout established labour but sadly in many maternity units midwives are looking after two or more women in labour and are unable to be with you in this way. Often you won’t have met the midwife who is looking after you until you arrive at your place of birth. You do have the option to employ an independent midwife; this will, as with a doula, cost you money although many women feel it is money that is very well spent.

 

Massage can really help during strong contractions, many women find they get lower back pain during contractions or that their contractions are helped by firm massage right at the base of the spine. We all tend to rub ourselves if we injure ourselves, there is good physiology behind that instinct, by rubbing an area of skin we divert the pain message from it’s pathway to the brain. Having said that, some women absolutely hate being touched during a contraction so it is important that birth partners listen to you and aren’t offended if you don’t want the massage they are offering.

Low light seems to help labour along. Birth is a very private and intimate thing to do, as intimate as sex and we very rarely choose to do that in a public place with a stranger looking on! Low light brings privacy and intimacy and is more restful. You might not be aware of the subliminal irritation of harsh overhead lighting in a delivery room but it will still be affecting you– birth partners should take control of the lighting as much as possible, turning off overhead lights and putting on wall lamps instead. At home, thinking about having a lamp or candles in the room in which you plan to give birth can be a useful bit of advance preparation.

Complementary therapies can be used to good effect both at home and in hospital but you usually need to get your partner briefed and equipped before labour. For more information on how to use different therapies see www.expectancy.co.uk. Some women take an aromatherapist or reflexologist into hospital with them but this may not be a low cost option – some doulas are also qualified homeopaths or aromatherapists. Some maternity units use therapies and have trained midwives to support you but others will not allow their midwives to practice in this way – finding out the position in your hospital is an important point in your place of birth research during pregnancy.

Breathing and Relaxation

There are many different ways of using breathing to cope with contractions but it is important not to get too technical about them and then panic because you can’t remember what to do on the day. The purpose of breathing techniques during contraction is to keep you relaxed, focussing on something other than the contraction itself and feeling in control. Going to pregnancy yoga, NCT or other antenatal classes will help – although NHS/Parentcraft sessions often don’t cover this so do check. There are also useful CD’s you can buy to help you practice and relax and visualise your way through contractions. Natal Hypnotherapy do an excellent series of CD’s, their range caters for all sorts of births including hospital, homebirths, VBAC and antenatal teachers often recommend them to their clients.

Here’s a quick guide to breathing and relaxing through contractions – remember there isn’t one “right” way, just what works for you.

As you feel the contraction coming, think “position” first of all and decide where you are going to be. Once in position do a great big sigh and let everything go as limp as possible. Once you’ve emptied your lungs your body will breathe in for you – it doesn’t matter if you breathe in through nose or mouth just let your body do it. As you breathe out again try to let your breath out really slowly through your mouth with an open mouth and relaxed jaw or try blowing the contraction away with a long, slow blow. The idea is that if you had a candle in front of you, you would be trying to make the flame flicker but not go out. All the time you are slowly breathing or blowing, keep focussing on the breath and on letting every part of you go as limp as possible. Imagine you are floating over the wave of the contraction.

Sometimes at the height of the contraction it helps to do short, quicker puffs to help you over the peak of the wave. Try puffing SOS in morse code, puff, puff, puff, blow, blow, blow, puff, puff, puff and see if anyone notices!

Sometimes blowing isn’t enough and you need to make noise as well – make sure your birth partners know that making noise is normal and a good idea providing it isn’t screaming. Experienced midwives often tell how far along labour is by what noises a woman is making. Remember the principle of keeping your jaw as relaxed as possible, women with tight, tense mouths are probably not dilating well . Try a long aaaaahhhhhh sound, or reciting a line of poetry or even singing, it’s still controlled breathing.

“I could hear my midwife saying to me through the contraction ‘ Just go saggy with it …’ and I did find that the more I let my body just take over, let the contraction take over and the less I fought it, the easier it was.”
— Jenny, 29, Derbyshire

Transition

Not everyone is aware of transition but for some women it is a really profoundly challenging part of their labour, when they need a lot of support from those around them. When the cervix reaches about 7-9 cm dilation the body begins to change the hormones in order to get ready for pushing. The contractions will also be at their most intense, coming one after the other with little or no gap in between and very, very strong. Some women can feel quite panicky and tearful or angry at this stage, some also can feel or be sick and it is not unusual to get very cold feet as the blood rushes to the uterus to get ready for pushing. Towards the end of a contraction you may grunt and start to push a little almost without noticing it.

How to cope

Make sure your partner has read all about labour and knows how to recognise this phase. Lots of reassurance from those all around you can be really helpful. There is a homeopathic remedy called Rescue Remedy which can be given to you, either dripped neat onto your tongue from the dropper or a couple of drops put in some water for you to sip. Socks for cold feet and hugs for tearfulness can help as well as everyone staying calm and positive. You are probably only an hour or so away from seeing your baby.

“I was making these huge bellowing noises and I remembered reading somewhere that you only make a few of these noises before the pushing starts which was helpful because the contractions were so overwhelming a bit of me wondered if I could possibly survive them. At one point I said “I can’t do this.” and my midwife said calmly “You ARE doing it.” and I thought ‘Yes, I really am aren’t I?’ After that it felt much better. I started to say “YEEEEESSS” during a contraction to will my baby down, down, down.”
— Lesley, 35, East Sussex

Second Stage – Pushing and Birthing

The cervix has now moved so far apart that if you were to consent to a vaginal examination, and it is not compulsory, the midwife wouldn’t be able to feel the cervix at all just the baby’s head beginning to move down into the birth canal.

Many women really enjoy second stage because they feel that at last they have something to do. It can however be really difficult at first to work out what to do. Try to remember that, especi if you are in an upright position, the uterus will do most of the work although it might not feel like that at the time!

All through first stage as the womb was contracting a big wedge of muscle has built up at the top of your womb, when the contractions change at the end of first stage that muscle stops pulling up and starts to push down on the baby, pushing him down through the birth canal. You will probably find that instinctively you start to push down as well as the baby’s head presses on your back passage (rectum) and that the urge to push becomes overwhelming. Some women never get an urge to push and it is fine to wait in that case until the baby’s had can be seen by the midwife before you make any effort. Some women barely push at all and just breathe the baby out – this is more likely if you are upright.

At the same time as bearing down with your diaphragm you are also using your internal muscles to push on the baby and trying to relax your pelvic floor as much as possible to let the baby out. This can feel a bit like rubbing your tummy and patting your head at the same time! If you can’t feel what you are doing try not to panic, sometimes moving into a different position can help.

“I really couldn’t work out what I should be doing so I tried pushing down my bottom as though I was having my bowels open. I felt the baby move and it was amazing, I could feel which set of muscles I should be using and I felt an enormous surge of power and that I could do it. It was wonderful!”
— Jenny, 29 Derbyshire

Helping Yourself

Keep using those UFO positions. You have about 30% more room in your pelvis if you are not lying on your back or semi sitting during the pushing stage as your coccyx (tailbone) can move out of the way. Some women think they need to squat but unless you are used to doing this it can be quite difficult. You still don’t have to lie down, indeed its probably easier to push if you don’t – try kneeling forward with your knees wide open or stand legs apart, leaning into partner’s arms and semi squatting or try hands and knees on a mattress. If it isn’t working try a radical change of position.

It is normal for it to take an hour or more for a first time mother to push her baby out -its designed to be a slow process to protect both mother and baby. However if progress is very slow try getting out of whatever position you are in and do one of the following:

  • Kneel on the floor and then keep one knee on the floor and put the other knee up so your foot is flat on the floor – lunge and rock forwards during the contraction. This changes the shape of your pelvis quite dramatically. You should only need to do this a few times and it can bring amazing results.
  • If you are at home use the stairs, go up and down the stairs sideways taking care to hold onto partner or bannisters – again this changes the pelvic shape and allows gravity to move the baby down.
  • If you are in a pool and progress is slow try getting out and moving around, sometimes you need solid ground to push.

What Birth Partners Can Do

It’s important for birth partners not to coach and cheerlead in second stage, women still need peace and concentration and to be encouraged to find their own pace and method of pushing. There is good research showing that women should not be told to hold their breath and push in second stage because it can distress the baby and exhaust the mother – birth partners should be prepared to intervene if this is happening.

Women are often very, very tired at this point and may need a lot of support to be upright as they push – if you absolutely have to lie on the bed then being on your side with your partner supporting your leg is less distressing for the baby and still allows your pelvis to open and the coccyx to move back.

Pushing can be extremely hot and hard work, partners can keep offering sips of water between contractions and cold flannels on the face.

Birthing Your Baby

As the baby’s head appears at the vaginal opening, the skin between the vagina and the anus begins to stretch. It is designed to stretch and it is important to remember this both in pregnancy and in labour. Women can get panicky at this point and decide to push the baby out really fast to get it all over with. This is bad news for your perineum and is really the opposite of what is needed. Panting or puffing and relaxing the pelvic floor and letting the baby ease out slowly will help you to birth your baby without damaging your perineum.

It can help to have imagined how it might feel – try putting a finger in each corner of your mouth and stretch your lips in an exaggerated smile. Feel the skin stretch and although it may feel like stinging and burning you will also notice it goes numb – the perineum is pretty similar. Imagine yourself puffing and breathing calmly through this stage, picture yourself doing it, the power of the human imagination is huge.

Most women don’t tear. Read that again and learn it off by heart as it may come as news to you – most women don’t tear. Of those that do, the vast majority need no stitches at all. It shouldn’t be a choice between cut or tear because most women will stretch but episiotomy, a cut to the perineum done by the midwife, is not done routinely in this country any more because a tear tends to be less deep and better at healing. Episiotomy is almost never done by more experienced, confident midwives who pride themselves on helping women avoid cuts and tears.

Helping Yourself

Stay upright unless you feel that the baby is coming too fast in which case if you are kneeling or standing upright ask your partners to help you onto hands and knees as this may slow things down and help you breathe baby out slowly.

The midwife may well be telling you not to push, this can be difficult so try short, sharp puffs as though you are blowing candle out one, by one. Panting can be difficult at this stage as you are often very dry mouthed.

Using a water pool to give birth in reduces tearing and the need for episiotomy. Perineal massage is also research proven to reduce perineal damage (see Preparing for Labour).

Birthing the Placenta

Many parents are so busy admiring the baby they are not thinking about the third stage of labour, the arrival of the placenta but the midwife is certainly very focussed on it as the birth process is not yet complete.

Once the baby is born, the placenta continue to pump blood containing oxygen and other nutrients to the baby via the umbilical cord which pulsates for several minutes after the birth.  This is believed to help the baby whilst he establishes his breathing .   Meanwhile a new raft of chemicals is being released by the mother’s brain and about twenty minutes or so after the baby is born these chemicals cause the blood vessels which connect the placenta to the internal wall of the womb to constrict and shut down.   At the same time more oxytocin is released causing the womb to contract again – the placenta peels off the inside of the womb and flops into the lower part of the womb.  As the woman moves, or pushes a little, the placenta emerges.  It is quite large, the size of a dinner plate but because it is soft it is much easier to birth than a baby.

 

Some women bleed a lot during third stage, in some countries they bleed so much it is life threatening, this is called a post-partum haemorrhage.  In this country we have very reliable drugs to stop a haemorrhage if it starts but rather than treat the problem if it occurs we have developed a practice of intervening with the normal process as routine.   Women are usually offered an injection just as the baby’s shoulders are born of syntometrine which is an artificial version of the drugs her body would normally produce to expel the placenta.

 

Often women are told that this is standard practice, quicker and recommended for all women without any more information than that.  There are a growing number of women who are challenging the expectation that they will have the drug and are opting for a physiological third stage, waiting for the placenta to arrive without drugs.
The physiological method avoids the use of syntometrine which can have some side effects on the mother such as nausea, vomiting, headaches, dizziness and raised blood pressure.   There are also very rare complications such as heart attack and postpartum eclampsia.

Another reason women may choose to have a physiological third stage is the worry that the clamping of the cord immediately after the birth, as commonly happens with a managed third stage, the baby doesn’t receive its full quote of blood, as much as 125 mls less than if the cord were left to pulsate as in a physiological third stage.  This could cause anaemia in some babies.

Some units don’t clamp the cord when giving syntometrine and the worry then is whether the baby might become over-transfused and whether this contributes to jaundice in the new baby.

It is common practice during a managed third stage for the midwife to pull on the cord and to put her hand on the bump and press down firmly – many women find this uncomfortable and instrusive during the first fifteen minutes of their baby’s life.

The AIMS booklet “Delivering Your Placenta” available from www.aims.org.uk also mentions the possibility that syntometrine might reach the baby and cause colic lasting for months after the birth.

Women are often sold the idea that a managed third stage is a better idea because it speeds up the process but it is also important that they are allowed to consider the possible disadvantages to themselves and the baby.  In a busy maternity unit the idea of speedy third stage is probably very attractive to overstretched midwives but as always it remains the mother’s choice.

Women are often advised to have a managed third stage if they are anaemic, have a blood clotting disorder, if their labour has been induced or has been very prolonged.  None of these have been research proven to always cause problems.

It is important that both midwife and birth partners are aware of the mum’s preference for third stage as she is often in no state to think straight or answer questions during the pushing when the question might be asked.   It is important not to mix the methods – pulling on the cord and pushing on the abdomen can be quite dangerous in a physiological third stage but some midwives aren’t always aware of this and birth partners may need to remind the midwife that this is not a managed third stage.

Some placentas can take an hour or more to appear.  Far from seeing this as a disadvantage, mums can choose to have the cord cut once it has stopped pulsating and then carry on enjoying skin to skin and feeding time with the baby.   Moving about, getting out of the birth pool or going to the loo after a little while might help the placenta to emerge. Feeding the baby if he is ready to feed might be especially helpful as women produce oxytocin when they breastfeed.

Try not to birth the placenta in the toilet, your poor midwife has to fish it out as it needs to be checked to ensure it is all out.   If you give birth to your in a waterpool it is usually suggested that you get out to birth the placenta, mainly because it is very hard to estimate blood loss in water.  Michel Odent, the French obstetrician and author of many books on childbirth once suggested in an article for the medical profession that birthing the placenta in water might cause an embolism in the mother.  Many units have produced policies based on this theory but it is only a theory and no research has been done to substantiate it.

There is still a lot we don’t know about third stage of labour – including what actually we mean by postpartum haemorrhage – some countries like the Netherlands where syntometrine isn’t routine, define it as a blood loss over 1000ml .  Some, as in the UK, define a postpartum haemorrhage as blood loss over 500ml.   Actually it is almost impossible to tell how much blood a woman has lost anyway, many experienced midwives would rather watch how the woman’s body is coping with the loss.  What does appear to be clear is that a healthy woman having a straightforward labour and birthing in the UK with a qualified midwife is not putting herself at risk by choosing to await the arrival of her placenta without drugs.

Further reading:

  • Expecting, Anna McGrail and Daphne Metland, Virago 2004
  • Birth and Beyond, Yehudi Gordon, Vermilion 2002
  • Stand and Deliver, And Other Brilliant Ways to Give Birth, Emma Mahoney, Thorsons 2005.