The Third and Fourth Stages of Labor

Your job is not quite finished. The placenta still needs to be expelled. The third stage usually lasts from 5 to 30 minutes. The nurse or caregiver keeps a hand on your abdomen to determine when the placenta separates from the wall of your uterus. Then he or she asks you to push it out. You may feel some cramps, but the discomfort is usually very slight.

The Fourth Stage

Immediately after birth, while you hold and admire your new baby, your doctor or midwife focuses on your well-being. The condition of your uterus and vagina is of major concern. It is important that your uterus remain contracted after birth, which keeps it from bleeding as much as when it is relaxed.

Most women lose about one cup of blood at the time of birth. While this may seem like a lot, remember that among the many other changes of pregnancy, your blood supply greatly increased. That excess blood is no longer needed; you lose some of it at the time of birth and continue to lose some over a period of several weeks (this discharge is called lochia). Your caregiver watches the amount of blood lost immediately after birth and, if necessary, takes measures to reduce the blood loss. These may include massaging your uterus vigorously, asking you to lightly stimulate your nipples, or giving you an injection of a medication such as Methergine (methyl-ergonovine) or Pitocin (oxytocin) that causes your uterus to contract.

Your doctor also checks your vagina to see if you need any stitches. If an episiotomy (an incision to make childbirth easier and to avoid tearing of tissues) was performed, you definitely need stitches. Some tearing of the vagina or perineum may also have occurred when the baby was born. Although the idea of tearing sounds rather unpleasant, be assured the tears (or cuts) are usually not serious and heal rapidly. If necessary, your doctor begins stitching within a few minutes after birth. You will receive a local anesthetic for pain relief if you have not already had one.

Childbirth is a natural process. Although labor may sound frightening and painful, it can be managed without complications and with wonderful results.

The Second Stage of Labor

The second stage is when the momentous occasion occurs. The feelings of love for your newborn baby -- and of relief -- will be incredible. The second stage ranges in length from 15 minutes to 3 or more hours.

When your cervix is fully dilated, the intense, out-of-control feelings may subside. The contractions often space out somewhat, and you may even get a short break from contractions (this is more likely with first-time mothers). It is always wonderful news when you are told your cervix is fully dilated and you can begin pushing whenever you feel like it.

During the second stage, you may find yourself holding your breath or slowly letting it out, while bearing down (something like, but much more than, what you do when having a bowel movement) and releasing your pelvic floor (relaxing the muscles in the area around your vagina). This last is most important because tensing the pelvic floor actually fights against the birth of your baby -- and it hurts much more than letting go.

A change in your contractions occurs in the second stage. Accompanying most contractions is a reflex need to strain or grunt, called an urge to push, which comes and goes three to five times per contraction. The combination of the uterine contraction and your bearing-down effort pushes the baby closer to the outside. It is hard work and it hurts, but it is also an exciting time, with lots of cheering and praise for your efforts. Most women find they have the strength to keep pushing.

The best way to push is to push only when your body makes it happen -- only when the urge to push comes. That way you won't hold your breath so long that you or the baby gets too little oxygen. The following is a routine many women use during second-stage contractions:

Greet the contraction with a long breath, and curl your body forward whether you are reclining, lying on your side, squatting, or sitting on a birthing chair.


Breathe as you did during first-stage contractions.


When you feel the reflex urge to push (it is unmistakable), follow it by grunting or holding your breath and bearing down. You may need reminders to relax your pelvic floor. The urge to push goes away after a few seconds. Then breathe again until the urge returns. Repeat this routine until the contraction ends.

Unless the baby is coming fast, you have time to change positions. Many childbirth educators encourage women to learn to squat comfortably before labor because this is such a helpful position for the second stage. When you squat, you give the baby more room to come down through your pelvis than in other positions. Sitting on a bedpan may help if you have trouble relaxing your pelvic floor.

Lying on your side is a good position if the baby is coming fast, if you have painful hemorrhoids, or if you must lie down for some reason. Resting on your hands and knees may help if the baby is large or experiencing a slowing of the heartbeat during contractions. Semi-sitting is a good position because you can see your caregiver and the baby as he comes out. This position is also a convenient one for your caregiver.

The lithotomy position, where the woman lies on her back with her legs in stirrups, used to be the way all women gave birth. Most women disliked the position. Their objections to it, plus the fact it sometimes caused slowing of the baby's heartbeat and other problems for the mother, finally led to discontinuation of its use as a routine position during most deliveries. Other caregivers continue to use the position, particularly with anesthetized births and deliveries assisted with forceps or vacuum extraction.

You might use several positions during the second stage, ending with semi-sitting or lying on your side for the actual birth. Discuss positions for the second stage with your caregiver in advance.

The Moment of Birth

You know when the baby's head emerges. You feel a stretching or burning sensation in your vagina. This is an exciting, intense time. You know the baby is almost here and may be tempted to push as hard as you can to help him fully emerge. That would be a mistake, however, because a sudden push could make the baby come out too quickly and damage your perineum (causing tearing). It is important for you not to push hard at this time. Let your uterus do the work alone. You should breathe rapidly and lightly (pant as animals do), so the baby can emerge gradually. Your caregiver gives instructions and helps the baby out slowly. You'll soon be holding your baby.

After the head emerges, the baby turns to one side, and a shoulder and then the whole body are born. And what a sense of relief you feel! Labor is over (or very nearly so). You have a baby. It may take a while for it all to sink in. In the meantime, you may be holding and caressing your baby or watching as a nurse or your doctor or midwife examines him and cares for him.

The First Stage of Labor

Labor is described as having three stages: the first stage, from the onset of progressing labor contractions until the cervix is completely dilated; the second stage, from complete dilation of the cervix until the baby is born; and the third stage, from the birth of the baby until the placenta is expelled.
A fourth stage, from the delivery of the placenta until the mother's medical condition is stable and safe, is also frequently mentioned.

The first stage is almost always the longest (2 to 24 or more hours), usually starting slowly and then speeding up when the dilation of the cervix reaches about four or five centimeters. Your contractions may not be clear and strong at first, but they will become longer, stronger, and closer together with time.

You may spend much of your time in the first stage trying to figure out if you are in labor or not. If you can be distracted from your contractions, it is unlikely you are in very advanced labor. On rare occasions, women have been unaware of labor until the baby was about to be born! In these cases, there really is no way to prevent a hectic scene unless a woman has had such a birth previously. Then she should watch carefully for any sign of labor -- subtle, preliminary, or absolutely clear.

As labor progresses, you will no longer have any question whether you are in labor. Its pace quickens, and the contractions usually become painful. Once you are certain you are in labor, go to the hospital or birthing center, or if the birth is to be at home, await your caregiver's arrival. Of course, if you have any concerns, feel free to go to the hospital. Be sure to take your bag and have needed items on hand.

You may become serious and quiet, focused on only one thing -- your labor. Jokes are not funny; world events lose their importance. You need support, encouragement, help, and comforting gestures from your partner, caregiver, and nurse. You are likely to have emotional ups and downs throughout labor. You may feel discouraged and may weep from time to time, but if you accept and understand what is happening and what to expect, you can recover from these down periods and go on.

Arrival at the Hospital


On arrival, your first stop is usually the admitting office, where you are asked to read and sign forms and indicate how you will pay for your hospital stay. However, hospital procedures vary considerably, so prior to going into labor, check with your hospital regarding their admitting policies -- especially their procedures for late-night and weekend admissions.


From there you go to the maternity ward, where a nurse greets you, does a quick health check on you, assesses your contractions and the baby's condition, and does a vaginal examination to establish how far along you are in labor.

From then on, hospitals vary widely in their routine care for labor. You may undergo various routines depending on what your doctor feels is best for you. In addition, your nurse periodically takes your temperature and blood pressure, monitors your baby's heartbeat, and feels your abdomen during contractions to determine how labor is progressing. Discuss the procedures in advance with your doctor and express your preferences.

Factors Influencing Labor


Factors you cannot control:

Size and shape of your pelvis


Size and shape of baby's head and shoulders


Baby's station, presentation, and position


The condition of your cervix when contractions begin


The power of your contractions


The amount of rest you have between contractions


Some aspects of your general health and your baby's well-being
Factors you can control, to some extent:

Your emotional state and attitude toward birth (optimism, confidence, and relaxation versus anxiety, fear, and tension)


Presence of helpful, caring partner(s)


Knowledge of what to expect


An environment and a professional staff that help you feel secure and well cared for


Good care of yourself (including good nourishment and good health habits)

Station refers to how low the baby is in the pelvis.

Presentation refers to which part of the baby's body emerges first (usually it is the head, but on occasion it maybe the buttocks, the feet, or even a shoulder).

Position refers to the location -- on the left or the right side of the mother -- and the orientation -- anterior (toward the mother's front), posterior (toward the mother's back), or transverse (lying crosswise) -- of a given part of the baby, specifically, the occiput (back of the head), brow, chin, shoulder, or sacrum (the bone at the lower end of the spinal column). For example, if a baby's position is left occipitoanterior, the back of the head is on the left, pointing toward the mother's front.

Mother's Activities During Labor


Once settled in at the hospital, you will find a routine for handling contractions, perhaps based on what you learned in childbirth classes. Many women learn and use the following routine:

Greet the contraction with a long sigh. As you breathe out, release all bodily tension.


At the same time, focus your attention in some way (for example, focus on your partner's face or on a picture or object of your choice; close your eyes and picture your cervix opening as your uterus contracts; picture a peaceful, relaxing place and picture yourself there; focus on music of your choice or the soothing voice of your partner; or focus on the feel of your partner holding or stroking you).


Breathe slowly and easily.


Maintain relaxation throughout the contraction. Stay limp. It may help if you focus on one part of your body with each breath out. Try to release tension in that part as you breathe out. Then focus on another part with the next breath.
You can follow this routine with every contraction and in any position -- lying down, sitting, standing, on your hands and knees. You can do it in the tub or shower, in bed, in the car, in a chair, in the hospital corridor, or in your room. You can lean on your partner, the wall, or your bed.

These techniques often keep pain within manageable limits for part or all of your labor. Women who use them generally need less pain medication than others. Indeed, some women do not need to use any pain medication when using these techniques.

Some women learn several types, or levels, of breathing to use progressively during labor. Besides the slow pattern just described, they may learn a lighter, faster, but still relaxing pattern and other variations.

Besides using a routine for each contraction, you should try to change position every 20 or 30 minutes, go to the bathroom every hour or so, and sip liquids or suck on ice after every contraction. These measures may be comforting.

You may find hot packs on the lower portion of your abdomen, your groin, and your perineum (external genital-rectal area); cold packs on the lower part of your back; and a cool, moist washcloth rubbed over your face and neck ease some discomfort. Being touched and rubbed, especially in tense, sore areas, such as the shoulders and the lower part of the back, helps a lot. If you feel a bit out of control, it helps when your partner holds you tightly or gently but firmly holds your head in his hands.

During intense periods, such as the transition phase (from about seven to ten centimeters of cervical dilation), you may feel almost out of control. You may feel your body is running away with you, and you are being swept along in a tide of intense sensations. Fighting these sensations is pointless.

You may feel an urge to push but be told that you are not yet fully dilated. It is important that -- for the time being -- you resist the urge to push. Pushing too soon could injure the cervix and perineal tissues and may lead to heavy bleeding. What helps the most is knowing nothing is wrong. Just accept that your body is in charge, and don't try to stay in control. Let your loved ones help you, moan and complain if you want to, and know it will not last too long.

What Is Labor?

Labor is a different experience for every woman and every birth. Many first-time mothers make the mistake of thinking they have entered labor prematurely, and may end making unnecessary trips to the hospital. To be fully prepared for labor, it's important to understand exactly what happens during this time.

The changes taking place in your body, placenta, and baby during the last three months of pregnancy accelerate at the end, culminating in labor. As the placenta ages and gradually loses its ability to maintain the pregnancy, the baby becomes strong and capable enough to survive outside the mother's body; the uterus begins to let go and expel the baby; and the mother becomes ready to give birth and to feed and nurture her baby.

Labor consists of rhythmic uterine contractions, which open the cervix and press the baby down through the birth canal and out of your body. The uterus is a big, strong, hollow muscle; when it contracts, it tightens and hardens. This may happen anywhere from 25 to 300 times during labor, which may take anywhere from a few hours to more than a day. The process involves not only your uterus but your entire body and mind; all your energy is devoted toward the one goal of giving birth to your baby.

How will you know when you are in labor? As basic as this question is, it is one of the most difficult to answer. It usually takes hours or even days to figure out whether your sensations are labor or something else (prelabor, or false labor). This is because labor does not begin suddenly. It evolves gradually. At some point, you or your doctor will recognize these sensations are true labor, meaning they are accompanied by increasing dilation of the cervix. This section describes the signs and sensations of labor to help you recognize it. It also describes the birth process, the emotions that accompany labor, and how your partner can help you the most.

If you are within a week or two of your due date, you generally may wait until you have an absolutely clear sign of labor before going to the hospital, although your caregiver may ask you to let him or her know if your bag of waters (amniotic sac surrounding the baby) seems to be leaking. If your pregnancy has been complicated by diabetes, high blood pressure, or other medical conditions, or if you have twins, your doctor may advise you to go to the hospital with the onset of preliminary signs. If you are several weeks before your due date, you should notify your doctor if you have any preliminary signs because they could indicate early or premature labor. Premature labor can often be stopped if treatment is begun early enough.

To determine whether your contractions are progressing (that is, becoming longer, stronger, and closer together), you need to time them. On a sheet of paper, list the times contractions begin and how long the contractions last. Time them in this way for an hour or two. If they are not progressing, stop for a while until the contractions seem different, then try timing them again.

You should call your caregiver or your hospital's labor and delivery ward to tell them you are in labor or to ask for advice. Be sure to report the status of your bag of waters; whether you have a bloody discharge (called bloody show, which you continue to pass throughout labor); how long and how many minutes apart your contractions are; and how strong or painful they feel to you.

Labor varies from woman to woman; even in the same woman each labor is different. Some labors are very fast, lasting only a few hours; some are average in length (about 15 or 16 hours for first-time mothers and 7 or 8 hours for women who have had babies before); some are very long, lasting a day or two. Some start slowly and then speed up unexpectedly; others start rapidly and then slow down. The amount of pain and fatigue varies also. It is best not to have definite expectations but to prepare yourself for the wide range of possibilities.

Physical Changes Before Labor

What about the mother? What changes do you experience in preparation for the birth? The changes that come with pregnancy affect not only the baby, the uterus, and the placenta, but also the mother's entire body, her mind, and her emotions.

For example, your breasts began changing as soon as you became pregnant. You may have noticed some breast changes (tenderness, tingling sensations, and feelings of heaviness) very early, even before you knew you were pregnant. These changes indicate your body is beginning to get ready for breast-feeding. By late pregnancy, you may notice more veins in your breasts, indicating the increased blood supply in the area. You may also notice your breasts are somewhat larger than they were before, and the areolae (the circles around your nipples) may have darkened. Inside the breasts, the milk-producing glands have grown larger. They even begin producing a substance called colostrum, which enables you to breast-feed as soon as the baby is born.

Other parts of your body also change in preparation for the birth. For example, the ligaments begin to soften. This is particularly helpful in the pelvis, through which the baby passes during birth. Flexible ligaments allow the pelvis to enlarge somewhat, making more room for the baby. These changes sometimes cause shooting pains in your hips, stiffness in the lower part of your back, or soreness in the front joint of your pelvis (the symphysis pubis) and the sacroiliac joints. Although inconvenient now, these changes really are a benefit during the birth process.

Like many women, you may experience heartburn and constipation, partly due to slowing of digestion and partly due to the size of the uterus, which crowds your stomach and intestines and causes you to burp up acid and have trouble moving your bowels. Despite these discomforts, there are benefits. Your body is able to absorb more nutrients from your digestive tract because of this slowing of digestion.

Your uterus undergoes vast changes in the last trimester of pregnancy. Obviously, it becomes much larger. It must accommodate the growing baby, the placenta (which weighs about one sixth of the baby's weight), and about one quart of amniotic fluid. As your uterus stretches around the growing baby inside, it becomes more sensitive. If you sneeze or bump your abdomen, your uterus often contracts immediately afterward. It is very sensitive to sudden pressure. Sometimes, while you rest, your uterus spontaneously contracts several times in a rhythm. More than one woman has wondered if she is in labor when this kind of contraction pattern occurs. These contractions, called Braxton Hicks contractions, are an indication the uterus has become more sensitive to the circulating oxytocin.

While Braxton Hicks contractions are not labor, they probably cause changes in your cervix that prepare it for labor. These changes include ripening (softening), effacement (thinning or shortening), and some dilation (opening) of the cervix prior to the onset of labor. Although you are probably unaware of it, the cervix, which is usually quite firm and thick, becomes soft and thin before labor begins. A ripe, thin cervix opens up much more easily than an unripe, thick cervix. The amount of ripening and thinning can be determined only with a vaginal examination. Effacement is measured as a percentage. For example, if your cervix is 25 percent effaced, it is 25 percent thinner, or shorter, than usual. (The cervix is usually about three to four centimeters long. Twenty-five percent effaced means 21/4 to 3 centimeters remain.) At 100 percent effacement, the cervix is paper thin.

Your cervix opens slightly before you go into labor. Referred to as dilation, this process is measured by feeling the circular rim of the cervix and estimating (in centimeters) the diameter of the opening. Many women are one or two centimeters dilated before they are aware of any signs of labor. During labor your cervix continues dilating to about ten centimeters (a circle about four inches across).
This preliminary work of the uterus in preparation for labor is thought to be controlled by the changing hormone production in the placenta, the baby, and the mother.

Childbirth Overview

As you enter the last three months of pregnancy, you may spend a lot of time thinking about the upcoming birth. Your large size and your baby's movements are constant reminders you will become a mother soon. You might be apprehensive about the birth and unsure of what to expect. Fortunately for you, countless mothers have gone through the very same process, and, while every birth is different, there are some basic elements they all have in common. In this article, we will cover the various aspects of childbirth, including:

Physical Changes Before Labor

In the final stages of pregnancy, the physical changes you experience will increase. Your body's behavior may be so different that it is difficult to distinguish when the actual labor process is beginning. We'll start by showing you which symptoms are and are not part of labor.


What Is Labor?

Every labor is a unique experience, and even women who have given birth before might not fully understand what is happening to their bodies. The right time to go to the hospital usually will depend on factors unique to your pregnancy, such as high blood pressure or other complications. We tell you some common symptoms and what they mean.


The First Stage of Labor

The first stage lasts the longest, from several hours to over a day. During this time, the cervix dilates completely so that the baby can come out. In fact, your entire body and mind will focus on the task of pushing the baby down the birth canal. On this page, you learn what you can and cannot control during this time.


The Second Stage of Labor

This is the moment you've been waiting for -- your baby is here! This part can be painful, but the power of becoming a mother pulls women through it. After all, this is what everything that has happened in the last nine months has led to. We tell you step-by-step what will happen in this stage.


The Third and Fourth Stages of Labor

Your baby is here, but your labor isn't quite complete. During the last stages you will expel the placenta and your doctor will take important steps for your well-being. While these stages may sound daunting, most new mothers find them to be much less unpleasant than they were expecting. On this page, you find out what happens immediately after birth.