Appendixes
Note: If you’re planning to have an epidural, use this chart until you receive the anesthesia. Then see Chapter 10, which explains how medications will affect the remainder of your labor.
Prelabor
What physical changes and events occur
• Your cervix begins to ripen, efface, and move forward.
• You have nonprogressing contractions and may have restless back pain, soft bowel movements, and menstrual-like cramps.
• May last for days.
How you may feel and how you may respond
• You feel tired, discouraged, anxious. You may be unable to sleep through contractions.
• May overestimate labor progress, start rituals, and go to birthplace (or call home birth midwife) too early.
• May focus more than necessary on the contractions.
What you can do to cope
• Engage in distracting activities and projects.
• Alternate distracting activities with restful ones such as taking a bath, listening to music, lying down, having a massage, and so on.
• Use labor-stimulating measures (only if you feel pressured to get into labor).
• Eat if you’re hungry (mostly carbohydrates).
• Drink to quench your thirst.
What your partner or doula can do to help you
• Review the route to the birthplace.
• Encourage you to eat and drink.
• Pack the vehicle; be sure there’s enough fuel in it.
• Time your contractions (five or six at a time) every few hours or when your labor seems to have changed.
• Ensure that you aren’t left alone. Help make this time pleasant for you.
• Alert your doula to be ready to come when you need her, if she’s not already with you.
• Enhance emotional security and reduce stress by creating a soothing, safe, private, and loving atmosphere.
First Stage of Labor: Early Labor
What physical changes and events occur
• Denotes the time from the
• onset of labor until your cervix
• is dilated to about 4 to 5 cm.
• Contractions are progressing, usually mild at first, then becoming longer, stronger, closer together.
• Your cervix continues ripening, effacing, and begins to dilate.
• May have bloody show.
• Your membranes may rupture (10 percent chance), but this usually happens later in labor.
• May have back pain with contractions.
How you may feel and how you may respond
• Same as in prelabor, plus:
• Have mixed feelings—excitement, confidence, and optimism; or anxiety and distress—often all at the same time.
• As contractions intensify, you can no longer be distracted during them.
What you can do to cope
• Begin using planned rituals (relax, breathe, and focus through each contraction) when the intensity of contractions stops you from doing distracting activities.
• Use slow breathing, releasing tension with each exhalation.
• Ask your doula for help.
• Contact your caregiver or birthplace as instructed, typically when your contractions have reached the 5-1-1 or 4-1-1, pattern (see page 244).
• Use comfort measures to relieve back pain.
What your partner or doula can do to help you
• Continue timing your contractions periodically. Call caregiver or birthplace when your contractions reach designated intensity, frequency, and length, or if your membranes rupture.
• Focus on you during contractions as soon as you begin doing a planned ritual.
• Give you constructive feedback, not false praise.
• Help you release tension in a selected area of your body with each exhalation.
• Remind you of positions and comfort techniques (see Chapter 11).
First Stage of Labor: Getting into Active Labor
What physical changes and events occur
• Your cervix is dilated 4 to 5 cm.
• Your contractions intensify and occur every 3 to 4 minutes, lasting 1 minute or longer.
• Your labor progress should begin to speed up when your cervix is 5 cm dilated.
How you may feel and how you may respond
• You probably head for your birthplace or call your home birth midwife.
• May struggle to remain “in control” and worry that labor is too hard and long.
• May become serious, withdrawn, and focused on your labor.
• You may recognize that labor isn’t within your control, leaving you feeling trapped. You may weep.
• You can no longer be distracted during contractions; you need your partner’s or doula’s undivided attention during them.
• Find unnecessary conversation annoying.
• May want pain medications.
• Can release control and accept your labor if you can move freely, feel safe and uninhibited, and have good support.
What you can do to cope
• Try to release your need to be in control; let labor happen as you discover what helps you cope (finding your spontaneous ritual).
• Maintain a rhythm with your breathing and movements, letting your partner or doula help as necessary.
• Try to continue slow breathing if you find it restful.
• Remember that labor progress should speed up soon.
• If you planned for an early epidural, you can probably receive it during this phase.
What your partner or doula can do to help you
• Drive to the birthplace carefully!
• Use massage (hand or foot), double hip squeeze, counter-pressure, slow dancing, and so on to help you cope (see Chapter 11).
• Rhythmically murmur soothing, encouraging words to you.
• Guide you with visualizations, imagery, rhythmic talk, or breath-counting—whatever helps you respond well.
• Help you keep a rhythm in your breathing, moaning, swaying, tapping, or whatever action you choose.
• Refrain from asking questions during contractions, and ask only simple yes-or-no questions between contractions.
• Help with your ritual (for example, stroking you, holding you, or talking to you through contractions) or simply stay by you if that’s all you require.
• Help you follow your preferences on pain medications (see page 187).
First Stage of Labor: Active Labor
What physical changes and events occur
• Your cervix dilates from 5 to 8 cm.
• Lasts on average 3 to 5 hours.
• If your baby is occiput posterior or her head is tilted to one side, dilation of your cervix may pause as your baby corrects her position.
• May have back pain (30 percent chance).
How you may feel and how you may respond
• You become calmer than before, now that you’ve discovered how to get through contractions.
• May enter the “birth zone” and become aware of little other than your labor.
What you can do to cope
• Same as for early labor and getting into active labor, plus:
• Take a bath for relaxation and pain relief.
• Stay hydrated by taking frequent sips of water or juice.
What your partner or doula can do to help you
• Same as for getting into active labor, plus:
• Stay by your side.
• Offer you liquids.
• Remind you to empty your bladder.
First Stage of Labor: Transition
What physical changes and events occur
• Your cervix dilates from 8 to 10 cm.
• Your baby begins to descend toward your vaginal opening.
• Contractions are long and very close together.
• Pain and intensity of labor is probably at its maximum.
• Likely lasts less than 2 hours if this is your first birth, or less than 1 hour if you’ve given birth before.
• As your cervix completes dilation, you may have a “lip” that remains.
How you may feel and how you may respond
• May feel scared or lost in labor; may be angry or frustrated.
• May want more help from others.
• May feel that you’ve reached your limit.
• May lose your rhythm and ritual.
• May cry out, tense, weep, or protest.
• May feel hot, then cold; may tremble.
• May feel nauseated; may vomit.
What you can do to cope
• Keep a rhythm.
• Follow your partner’s or doula’s lead with Take Charge Routine (see page 256).
• Hang in there! Remember that you’re almost ready to push and will feel better soon. If you can keep a rhythm and follow a ritual now, you’re better able to continue laboring without medications (if that’s your wish and if your labor progress remains normal).
• If you want an epidural, you can get it at this time as long as your labor isn’t moving too fast.
What your partner or doula can do to help you
• Maintain a confident, calm, optimistic manner; keep eye contact with you.
• Use the Take Charge Routine (see page 256) if you’re panicky or if your eyes are clenched shut and your expression is anguished, or if you can’t maintain a rhythm.
• Remind you that transition means you’re almost ready to push out your baby.
• Hold you tightly (but not rub your body), if that’s what you want.
• Keep encouraging you and never give up.
• Let you weep, if you must, while acknowledging your pain.
Second Stage of Labor: Resting Phase
What physical changes and events occur
• Denotes the time from complete dilation to when you begin to push.
• For up to 20 minutes, you may have few noticeable contractions (if any) or have no urge to push.
• After your baby’s head has slipped through your cervix, your uterus may need time to tighten around the rest of your baby’s body before you can begin to push.
How you may feel and how you may respond
• Feel relief, optimism, confidence, and pain-free.
• Have renewed energy, enthusiasm, hope, even if you don’t experience a pause in contractions.
• No longer in the “birth zone”—you’re clearheaded, talkative, and more aware of your surroundings.
What you can do to cope
• Rest or doze, if you can.
• If you want to push spontaneously when you have the urge, remind your nurse or caregiver of this preference.
• Review positions; review how to push and how to relax your pelvic floor muscles.
• If the resting phase lasts more than 20 minutes, change to upright positions to encourage an urge to push.
What your partner or doula can do to help you
• Should match your enthusiasm (but not overly so).
• Use this lull to renew energy (drink a beverage, close eyes and rest for a moment, use the restroom, and so on). If leaving the room, return promptly.
• Help you change positions, if necessary or desired.
Second Stage of Labor: Descent Phase
What physical changes and events occur
• Your baby rotates and descends into your birth canal.
• Oxytocin surges cause an urge to push, which may be mild at first, but becomes compelling and irresistible. You begin to push reflexively with contractions.
• Contractions aren’t as close together as they were in transition, and they may be shorter.
• May last for a few minutes or up to 2 hours.
• At first, your baby’s head can’t be seen, then it appears at your vaginal opening when you push and retreats between pushes.
• Your caregiver supports your perineum, applies warm compresses, and may direct your pushing.
How you may feel and how you may respond
• May feel inadequate in pushing until you get the hang of it.
• May find this phase rewarding, but you may find it painful and tedious. Either way, you’re working hard.
• May find the pressure in your vagina alarming and fear it will worsen, making you “hold back” from pushing (see page 262).
• May feel less pain as your baby’s head repositions.
What you can do to cope
• Hold your breath and strain when the contraction makes you feel that you can’t avoid pushing. You may bellow or cry out with the effort.
• Try to bulge your pelvic floor (see page 96).
• Consider touching your baby’s head or watching her progress in a mirror.
• If you’re holding back, or if pushing is painful, try to push into the pain and through it. Doing so will feel better than stopping when it hurts.
• Change your position every 30 minutes for comfort or to speed up labor progress.
• Consider directed or prolonged pushing if your labor isn’t adequately progressing with spontaneous bearing down.
• If using directed pushing, follow the directions for when and how long to hold your breath and strain.
What your partner or doula can do to help you
• Encourage and praise your efforts. (Should not yell, “Push!”).
• Apply cool, damp cloths to your forehead, cheeks, neck, and chest.
• Report on your progress (as soon as your baby’s head is visible).
• Remind you to release tension in your perineum.
• Remind your caregiver of your feelings about episiotomy, if appropriate.
• Support your position and help you change positions.
• If pushing is ineffective, remind you to open your eyes and look toward where your baby is emerging (may use a mirror).
Second Stage of Labor: Crowning and Birth
What physical changes and events occur
• Your baby’s head emerges; it no longer retracts into your vaginal opening between contractions.
• Your perineum and area around your urethra are most vulnerable to tearing in this phase.
• Your caregiver either supports your perineum (often with warm compresses) or does an episiotomy (unlikely).
How you may feel and how you may respond
• Feel excited because your baby’s birth will be very soon.
• May feel a burning sensation from vaginal stretching.
• May have mixed feelings: You may be tempted to push hard to get the birth over with, despite the burning. Or you may fear the burning feeling and become reluctant to push.
What you can do to cope
• Recognize the burning as a sign that labor is almost over.
• Use your partner’s help with positions.
• To slow the birth of your baby’s head and protect your perineum, stop pushing and pant or blow when your caregiver tells you to do so.
• Rejoice in your baby’s birth!
What your partner or doula can do to help you
• Support you as you change positions.
• Refrain from rushing you; help you keep from pushing as needed.
• Say little or nothing when your caregiver is directing you to slow the birth of your baby’s head.
• Rejoice in your baby’s birth!
Third Stage of Labor
What physical changes and events occur
• Lasts up to 30 minutes.
• Your baby’s umbilical cord is clamped and cut.
• Your baby’s condition is evaluated using the Apgar score.
• If your baby is fine and hospital policy allows, your baby is placed on your bare abdomen or chest.
• Your uterus contracts and shrinks, the placenta separates from your uterine wall. You expel the placenta with a few pushes.
• You may briefly tremble uncontrollably. (This is a normal reaction to giving birth.)
• Your caregiver checks your uterus to confirm it’s contracting, and checks your birth canal for tears.
How you may feel and how you may respond
• Feel relief that labor is over.
• Become engrossed with your baby.
• Feel concern over trembling.
• Feel alarm if contractions are still painful.
• Feel surprise at the discomfort when your caregiver examines your birth canal or massages your uterus after the placenta is expelled.
What you can do to cope
• Move away clothing so your baby can lie skin-to-skin with you.
• Don’t rush breastfeeding. Your baby needs time to acclimate before she’s ready to feed. Let her show you she’s ready to start suckling (see page 410).
• Ask for a warm blanket to stop trembling.
• Use light breathing and focus on your partner or doula during uterine massage and the examination or stitching of your perineum.
• Try to be patient during postpartum procedures. You’ll have time to focus on your baby soon.
What your partner or doula can do to help you
• Help you get your baby onto your bare abdomen.
• Help you breathe and focus through any painful procedures.
• Get you a warm blanket if you’re trembling.
• Open shirt and snuggle skin-to-skin with your baby, if you can’t hold her right away.
• Request that routine newborn procedures (such as weighing your baby or giving her a bath) be delayed for at least an hour so you can bond with your baby.
• Enjoy this time with your new family!