Early Labor - 0-6cm

Early labor (or latent phase) is the stage from the start of contractions to 5-6cm dilated. The length of this stage is highly variable - for a first pregnancy, this stage can last several days. Unless there are concerns for your health or your baby’s health, it is best to try and let this stage progress naturally.

What You May Feel During Early Labor

Early labor will be recognized by the start of your contractions. These will be painful tightenings of your belly, lower pelvis, and sometimes your back. They often start gently and become gradually stronger and longer. These contractions may feel like strong period cramps at first.

Contractions in early labor typically:

• are irregular at first

• become more regular, happening every 5-20 minutes

• become stronger as your labor progresses

• allow you to continue to speak during a contraction

• last less than one minute (60 seconds)

Where To Be During Early Labor

It is best to be at home during early labor. You will tend to be more comfortable, more mobile, and more able to rest there as compared to the hospital. These are all things that can help a labor progress well.

Some women are concerned that they should be in hospital during this part of labor. There are many studies that show that this is not ideal. You are more likely to have interventions that may be unnecessary if you remain in hospital during early labor. There are also higher C-section rates for women admitted in the latent phase instead of the active phase.

If you have had complications in your pregnancy or certain risk factors, you may need to be admitted in early labor. These risks are different than those in the studies mentioned above and are unique to each woman.

Pain Management in Early Labor

Pain is one of women’s major concerns during labor and is often one of the reasons they feel they should remain in hospital. There are many ways to manage pain during this time and some of the most effective ways do not involve medications at all.

Home Strategies for Pain Management

• Having your support person with you

  • The presence of someone to provide emotional and physical support can be very effective in achieving comfort

• Remain physically active and mobile

  • Allow yourself to walk and move around - this can help distract you from the pain of contractions, as well as encourage baby’s head to move down for labor to progress

• Take a shower

  • This can be a super-effective way to help cope with contraction pain

• Get your rest, have a nap

  • Labor can be an exhausting process - if you are able to sleep during the early stages of labor, it will help you feel more ready for the later stages

• Try some of the movements from Spinning Babies®

  • These are all techniques that can be done in pregnancy and in labor

    • It is worth exploring their website and trying some of the techniques prior to labor

  • Forward-leaning inversion

  • Rebozo sifting

  • Side-lying release

• Try the Miles Circuit

  • This was designed for encouraging a baby into a good position before labor, but can also be used during labor to help relieve back pain and encourage baby into a good position

  • This is another website worth exploring prior to your labor

• Massage

  • Having a support person massage your lower back, apply firm pressure to the place where the back and hips join, or even massage your feet or legs can provide significant comfort during early labor

Medical Pain Management in Early Labor

• If you find your are not coping well with labor pains and other management strategies aren’t enough, there are pain medicines that can be used in labor

• The main medicine used in early labor is morphine, an opioid pain medicine

  • It is given as an injection into the muscle, usually your hip or your arm

  • It is almost always given with Gravol in the same injection - the main side effect people notice with morphine tends to be nausea or vomiting

• This medication can be given every four hours in early labor as needed

• You may find that it makes you feel a bit sleepy - this is a very common effect of the morphine and gravol, which has the benefit of allowing you to get some much needed rest during early labor

Active Labor - 6-10cm

Active labor is what women commonly think of when they think of ‘labor’. This is the time when your contractions become more regular, more intense, and longer lasting. It is also the time when you will be admitted to hospital. You will have an IV placed and a small amount of bloodwork to check your hemoglobin (red blood cell count).

In your reading about pregnancy and labor, you will likely see the start of active labor listed as when the cervix is dilated to 4cm, 5cm, or 6cm. For many decades, 4cm was accepted as the start of active labor. More recent studies have found that 5 or 6cm is more accurate. Your doctor will not judge active labor based on just your dilation, but on other aspects of the cervix and your contraction pattern to determine when you should be admitted to hospital.

Pain Management in Active Labor

Non-Medicine Pain Management

• Continue to move and be active as you feel able

  • This helps to give you a feeling of control over your body and your contractions

  • It also helps to allow baby to find the path of least resistance through the pelvis to make the second stage of labor easier

• Breathing relaxation techniques

  • This may seem cliched from TV and movie versions of labor, but control of your breathing is important for managing your pain

  • There are many different breathing patterns that can be effective

    • Take the time before labor to look at different patterns and see which ones appeal to you

      • Belly breathing or panting breaths

      • Learn at a prenatal class

      • Search online for different techniques

• Hot shower

• Massage

• Techniques from Spinning Babies®

• Rest, have a nap

  • This might be more difficult as your contractions increase in intensity, but if you are able to rest between contractions this is a good chance to do so

Medicine Pain Management in Active Labor

Nitrous Oxide - Entonox, Laughing Gas

• This is an inhaled medicine that works on several parts of the pain pathway in our bodies

• It can be very effect to lower the intensity of contractions

• You breathe it in during contractions to provide pain relieve, then breathe normal air in-between contractions

• There are no known effects of nitrous oxide on your baby

Opioid Pain Medicine - Morphine and Fentanyl

• If you are still in the early stages of active labor and it will still be hours until baby is born, morphine can still be used in active labor

• As you progress in labor and get closer to full dilation and the pushing stage, we can offer fentanyl through your IV

  • Many women are fearful about fentanyl because of the opioid overdose crisis

  • The fentanyl that you would receive in hospital is from a clean, pharmacy source and given at known dosing

  • It is a short-acting medicine that leaves your body (and your baby’s body) in 15-30 minutes

  • It is used in active labor both because it is effective for pain control and because of its short action, so that it passes quickly from your baby’s body

    • There is a very small risk that if it is given too close to the time of delivery, your baby may be slow to breathe well and need some support for this

Epidural Pain Management

• An epidural involves putting a very small tube into the back just beside the spinal column

  • It does not enter the spinal fluid or touch the spinal cord

  • Instead, it allows medicine to flow around the nerves from the spine to provide pain relief

• The epidural is placed by an anesthetist, a specialist doctor trained in the procedure

• The medicine in an epidural is a combination of bupivicaine (a long acting form of lidocaine/novocaine) and fentanyl

• The epidural provides partial numbness from the belly down

  • Often it also causes some weakness in your legs which may make it more difficult to walk while it is in place

• The epidural continues to provide medication while it is in place and also allows you to press a button for a ‘top-up’ of pain relief

• An epidural can cause your blood pressure to become lower because of the medications and its effect on the nervous system

  • Your blood pressure will be checked frequently when the epidural is started

• An epidural can also cause your baby to become more sleepy in the womb, picked up by changes in the heartbeat

  • Your baby’s heart beat will be constantly monitored at the start of the epidural

  • You will be able to take breaks from this monitoring once we have seen that baby keeps a normal heartbeat for a certain amount of time

Second Stage - Full Dilation to Delivery

The second stage of labor starts once you are fully dilated and lasts until your baby is delivered.

Not every woman starts pushing right away once fully dilated. In fact, allowing time for passive descent can make the pushing part shorter and easier. Passive descent means allowing contractions to help move baby further down without any active pushing. For women who have never had children, passive descent may be allowed for up to 2 hours; for women who have previously had children, up to 1 hour. Your doctor will continue to check that your baby is moving down during this stage.

Pushing

Your efforts in pushing during contractions is what allows your baby to be born. It is an intense and often painful part of labor. Women often describe the urge to push as the feeling of needing to have a bowel movement. This feeling is a good starting point, as you want to try and direct your pushing efforts low in the pelvis towards your bottom. It may take a few contractions with direction from your doctor and nurse to understand how to push effectively.

Pushing tends to be most effective if you are able to hold your breath while pushing to direct all your energy into the push. As your contraction starts to build, take a deep breath in that fills the lungs. Hold your breath as you curl around your belly and push down into your pelvis and bottom. Try to allow the rest of your body to remain loose and relaxed with all of the pressure directed into the push. Try to push for at least 5 seconds, preferably 10. Let the rest of your breath out and fill your lungs again to start another push. Try for 3 pushes per contraction.

Your baby’s head should come lower with every push. At one point, your baby’s head needs to under your pubic bone before the head stays at the perineum (the muscles and skin at the bottom of the vagina). Women often feel an incredible increase in pressure and a burning feeling at this point. At this point, your doctor will often ask you to stop doing large pushes and instead do small controlled pushes. This allows baby’s head to ease out gently and stretch the skin rather than tear the skin. Once baby’s head is out, the shoulders and body typically follow quite quickly and baby will be handed up to you.

Positions for Pushing

There is no ‘right’ position to deliver in. A lot of women do deliver reclined on their back with their legs out to the side. However, you are encouraged to try different positions during position to find one that feels right to you and allows your baby to come down well with each push.

Other common positions that women use during labor include:

• Laying on their side with the top leg pulled back

• Hands and knees

• Kneeling, leaning on the bed or a bar

• Squatting, using a bar or their partner for support

Pain Management in the Second Stage of Labor

Fentanyl

Early during the second stage, fentanyl can still be used if baby is not close to being delivered yet.

As the second stage progresses, you will no longer be offered fentanyl as it becomes more likely for the medicine to remain in baby’s body and cause breathing trouble when baby is born.

Epidural Pain Management

If you had an epidural placed during active labor, this can continue to be effective during the second stage of labor.

You may still have the opportunity to receive an epidural at the start of second stage if an anesthetist is immediately available and you do not yet have the urge to push. However, it is not uncommon for a woman to need to start pushing before an epidural can be placed.

Pushing Into the Pain

It is important for you to feel your contractions during the second stage so that you can coordinate your pushes with the contractions. Your doctor or nurse will often encourage you to ‘push into the pain’ as the pain is often where baby’s head is at the moment. This can help change the pain from simple pain into a goal and a focus.

Third Stage and Onward - Placenta and Post-Partum

After your baby is born, the placenta will be delivered as well. This usually happens after the cord has been cut - as long as baby is doing well, we try to wait at least 2 minutes before cutting the cord.

The placenta is much easier to deliver than your baby, as it is much smaller and it is soft. Your doctor will ask you to do some gentle pushing to assist in the delivery while they pull gently on the umbilical cord.

Your nurse or doctor will then massage your lower belly to ensure that the placenta is becoming firmer and smaller - this helps to prevent post-partum bleeding. It can be a very uncomfortable feeling but is important to prevent bleeding. In the event that you do have extra bleeding, you may receive some extra medication through the IV or even placed into the rectum (bum). Your doctor may also have to reach into the vagina to clear out blood clots or provide pressure to the uterus.

This is then the time that your doctor will place any stitches if you had a tear during your delivery. They will put in some freezing with a needle then place the stitches. Even with freezing, this can be uncomfortable so using Entonox can be helpful, as can using a top-up of your epidural, if you have one.

You and your baby will stay skin to skin for the first hour of life and is a good time to try baby’s first feeding. After this time, your doctor will take baby to the warmer to do a head to toe examination. Your doctor and nurse will also weight baby at this time, as well as measure their head and their length.

You will stay in your delivery room for 2-4 hours after delivery and then you will move to the post-partum ward. Unless the post-partum word is overly full, mom’s and baby’s will have a room to themselves, with a fold-out cot for your support person.