Now that you understand how your body works in labour, you’re hopefully feeling confident and empowered, equipped with a set of tools you can use to make your birth the positive experience you want. You’re almost ready for action!
We’ve talked about the ‘up stage’ of labour, in which the cervix dilates and opens, and the ‘down stage’ of labour, where the baby descends and is born, but now I’m going to tell you that there is a little more to it than that.
There are in fact three stages of labour (four, actually, if you include early labour) and although very different things happen in every stage, each is as significant and important as the rest. You’ll notice, however, that there are many more than three (or four) terms used to describe the different stages of labour and it can be confusing to say the least! So, in order to make things clear, in this chapter I’m going to break it all down, so you understand what is happening at each stage, from start to finish, and when to use the hypnobirthing techniques you’ve learnt.
In hospitals, and indeed within your maternity notes, the stages of labour are identified in chronological order simply as ‘first’, ‘second’ and ‘third’ stage. Midwives will generally document in your notes how long each stage lasts.
You are said to have entered the ‘first stage’ of labour once you are 4cm dilated. This means that upon an internal examination (not mandatory), your cervix is deemed to be approximately 4cm open. This first stage ends when you’re believed to be fully dilated, i.e. when your cervix has opened to approximately 10cm. This stage is also referred to as ‘established labour’ or ‘active labour’, and in hypnobirthing this is what we call the ‘up stage’ – where the muscles of the uterus are drawing up, you are doing your up breathing through each surge, and your cervix is softening and opening.
You may have spotted a few flaws in the descriptions here already.
Firstly, if the ‘first’ stage begins when you are already 4cm dilated . . . what goes before? Is there a pre-first stage? Well, that’s why I mentioned that there are actually four stages. Everything that happens before being 4cm dilated is counted as ‘early labour’ or ‘the latent phase’. For some women, early labour will be less than an hour as things quickly become established, but for others early labour can be days with on-and-off, irregular surges.
Luckily, things tend to progress a little more predictably once labour is well established.
The second flaw you might have spotted is that there is a lot of talk about measurements: the first stage is timed from when you are 4cm dilated through to 10cm. So how do you know when the first stage has begun? How do you know if things are established? How do you even measure the cervix?
In answer to the last hypothetical question, to ‘measure’ how many centimetres you are dilated requires you to have an internal examination. A midwife or doctor will place their index and middle fingers inside your vagina, reach upwards and just into the cervix and then spread their two fingers apart and estimate (guess) how many centimetres open the gap is. It’s not an exact measurement by any stretch (excuse the pun) of the imagination. It’s just an approximate estimate. And obviously when you’re at home in early labour you will have no idea how many centimetres open your cervix is – and I’m certainly not encouraging you to try and find out for yourself! In place of internal examinations and measurements, you can gauge (less invasively) how things are progressing by timing the frequency of the surges, their duration and noting their intensity. This is something I’d encourage you to do when at home in early labour and, you’ll be happy to know, there is now an app to help you with that! You’ll find it listed in the resources section at the back of this book.
Once your surges have started coming they will, at some point, build in all three ways: frequency, duration and intensity. For some people, the surges might become more frequent at first, but last only twenty seconds or so. Others will get nice, strong surges that last a good minute but remain irregular. Labour begins differently for everyone, and even for the same woman from one birth to the next: no two are ever the same. So, (admittedly) somewhat unhelpfully, there are no rules. But what you can rely on is that, at some point, all three elements will come together and you will be having three surges in every ten-minute period (frequency), each surge will last approximately forty-five seconds to one minute (duration) and they will be good and strong (intensity). It’s at this point that you can consider yourself to be in established labour (without measurement) and this would be the time to travel into the birth centre or hospital, or to call your midwife out to you if having a home birth. (You will usually be advised of the protocol in your area at your thirty-four-week midwife appointment when discussing your birthplace choice.)
This is also known as the magic 3/10/45 and is worth remembering so as to save yourself unnecessary trips to and from the birth centre or hospital: you will usually be sent home if you travel in too soon and things are not yet established/you’re not yet 4cm dilated. So remember: you want a regular pattern of three surges every ten minutes, with each surge lasting at least forty-five seconds.
In hypnobirthing we refer to this first stage of established labour as the ‘up stage’, as I discussed in the chapter on breathing. We call it the up stage because the uterus muscles are drawing up, and every time you experience a surge you will feel the muscles tighten and lift, like a wave, to a peak of intensity, and then release. The feeling is really a lot like waves. Whilst this is happening, and the outer layer of the uterus muscles draws up with each surge, the cervix is softening, shortening and then opening.
This is when you use your up breathing: close your eyes, inhale through your nose, for a count of four, feel your chest rise and expand and think to yourself ‘inhale peace’. Then, exhale slowly through your mouth for a count of eight, feeling all your muscles relax and release, thinking to yourself ‘exhale tension’. Repeat this four times whilst experiencing a surge and then, once you’ve completed the four repetitions, the surge will have passed and you can go back to your regular breathing. Every time you feel another surge come, you do the same again: in for four, out for eight, four times over. And that’s it! Up breathing for the up stage of labour.
This first stage/up stage/established or active labour stage – the real deal if you will – is usually the longest stage of labour. The second stage, also known as the down stage (where you birth your baby), is normally significantly shorter. The up stage is likely to be several hours, whereas the down stage can be anything from a few minutes through to a maximum of around two hours.
The good news is that throughout the up stage you’ll be using your up-breathing technique, which is a lovely, calming, relaxing breath and feels nice to do. You’ll also be enjoying the light-touch massage, the arm stroking and of course being waited on with drinks and treats. You’ll ideally be soaking up the full spa-like experience with room spray, candle lights and spa music playing. It may be several hours, but it can be several glorious hours where you feel like a goddess!
Once you’re fully dilated, you may be aware of a transition. Transition simply means transitioning from one stage of labour to the next. In this case the first stage to the second stage – the up stage to the down stage. However, transition can be experienced in different ways.
For some women, transition is seamless and goes unnoticed – one minute they’re having a regular surge and the next minute their body is pushing involuntarily and they know they have entered the down stage of labour. For others there is a noticeable change – the surges slow down and become more gentle, almost as if their body is giving them an opportunity to rest before the next stage. Some women have a ‘wobble’, or slight panic. It’s thought the reason for this is that the body releases a small amount of adrenaline so that the mother’s senses are heightened and she has the opportunity to check the environment one last time to make sure it’s safe, before the baby makes its descent and is born.
It’s common at this point for women to doubt themselves and say they can’t do it, or that they want be somewhere else or they want an epidural. The good news is that this moment of panic passes quickly, which is why so many women refer to it as ‘a wobble’. The key thing is that birth partners remain calm and offer reassurance, reminding Mum that she has done all the hard work now and is so close to meeting her baby.
Now on to the ‘second stage’, as it will state in your maternity notes, or the ‘down stage’ as we call it in hypnobirthing. This is the stage in which baby descends down the birth canal and is born.
The second stage, or the ‘down stage’, is likely to be much shorter than the first stage. You have already done most of the hard work by dilating to 10cm, so it’s now ‘just’ a case of baby moving down a few inches and being born. Lots of women seem to worry about this stage more than any others. I think people tend to fixate on the moment of birth and the effort it will take – not helped of course by every depiction of a baby being born in the media ever! But actually, the majority of the ‘hard’ work will already have been done. And this moment, the one where your baby actually passes through and is born into the world is relatively quick in comparison and can feel amazing! You will feel your body work powerfully and you get to feel your baby for the first time as she or he moves down and is born. It can be utterly incredible and something women want to do over and over again. Really!
The most helpful thing you can do at this stage is to relax. Allow everything to soften and open and stretch as it’s designed to. The more relaxed you are, the easier and quicker this stage will be, for you and your baby. Gravity also helps massively. In contrast, if you are fearful, everything will tense up and you will effectively slow down the descent of your baby and make it more difficult for your baby to be born without assistance. So, try and reframe so that you look forward to this stage and meeting your baby. When you feel your body begin to push downwards and you feel baby descend, you know you are now so close to holding your baby in your arms! I get goosebumps just thinking about it. It is the most amazing sensation.
As we’ve already discussed, this is called the down stage because the muscles of the uterus change direction now and the inner layer of the uterus muscles begin to push down powerfully with each surge. The baby moves down the birth canal and is born. To keep things simple and straightforward and easy to remember, during the down stage of labour you do your down breathing: take a nice, quick breath in through the nose, feel your lungs expand and then exhale through the mouth, but with focus and intent. Channel your exhalation down through your body and feel your muscles move downwards with your breath. You want to ensure you’re working with your body and not against it!
This stage is also sometimes referred to as the ‘pushing stage’. If you’ve ever seen a woman give birth in a film, as we have already discussed, they are always lying on their backs, legs often in stirrups, red in the face, sweaty and swearing whilst being coached aggressively to push. This is at best an oft-repeated, boring Hollywood narrative and at worst, harmful and destructive – an example of how the media is responsible for conditioning women to believe that birth is something to fear. The good news is that this is categorically not how birth should be or, indeed, how it actually is in real life. It’s very common to believe that in this down stage of labour you need to actively push or force your baby out with great effort. I believe this is mainly because it’s all we’ve ever seen happen when birth is shown on TV. This, however, is not true.
Your body will push your baby out! Your uterus muscles – specifically the inner layer of horizontal rings that have been gathered upwards during the up stage of labour, and which are now bunched in a thick band at the top of your uterus – will, in the down stage of labour, begin to push downwards powerfully with each surge. It’s these muscles that will push your baby out. You don’t need to actively push. You just need to relax and allow your body to do what it’s designed to do. Trust your body! Your uterus is a finely tuned muscle that has evolved perfectly over millions of years. Trust your uterus! It knows what to do.
People always tend to stare in disbelief upon hearing this because it’s at such odds with their expectations. But it’s true. If you were unconscious (hopefully that will never be the case) your body would still be capable of birthing your baby! Those muscles are powerful and perfectly designed. It’s not that no pushing needs to take place – something needs to push! Your baby won’t just plop out. But it’s your body, your muscles which will do the pushing. You don’t need to actively force or push anything.
One of the reasons why this stage can sometimes take a long time is that the woman will, without realising, be bracing and drawing up her pelvic floor and tensing all her core muscles. This creates an internal struggle or battle between the muscle groups: the uterus muscles working hard to try and birth the baby and the other muscles tensing, tightening and drawing up to prevent the descent of the baby. That’s why the best thing you can do is to relax and breathe through the surges and by doing so, allow your uterus muscles to work to their full potential and birth your baby quickly, easily and gently.
You do not need to forcibly push to get your baby out! Your body is designed to do the job. Just go with your body and avoid tensing and hindering progress. Use your breath to help your muscles do their job. Work with your body, not against it.
The only reason you would possibly be advised to push or have a midwife or doctor coaching you to push – which is called coached pushing – is if the baby is in distress and therefore there is a need to speed up the birth, or because you’re on your back and therefore haven’t got gravity on your side and, as a consequence, might need to put some extra effort in because your uterus muscles, powerful as they are, might not be able to push a baby uphill and out! If you’ve had an epidural this could be the reason why you’re on your back on the bed and would increase the need for coached pushing, partly because your body hasn’t got gravity on its side, but also because you can’t feel when your body is surging/pushing so a midwife would let you know and coach you to push during each surge.
But if all is well, and you’re in a good, upright, forward and open position, then there is no need to speed up birth and you can trust that your body will do its job. Trust that uterus!
The time of the second stage or down stage of labour is recorded in your notes as being the time it takes from when you’re fully dilated through to the birth of your baby. If you’ve not had internal examinations, then this is the time from when your body starts to push through to the birth of your baby.
The more relaxed you are, the easier and quicker it will be. As I mentioned, this stage can be anywhere from a couple of minutes through to around the two-hour mark. If your body has been pushing for two hours and baby is not descending, intervention would normally be offered at this point. As with any offer of intervention, you would need to use your B.R.A.I.N. to help you decide what you want to do. It might well be the time and place for intervention, and you may be happy to embrace help at this point, or you might prefer to continue as you are. I would suspect that how baby is doing and how you are feeling would be important factors to consider at this point. If you and your baby are tiring then help might be welcomed. If you are both fine, you may be happier to continue as you are for a while longer.
During the second stage or down stage, if all is well you can be confident that you won’t be coached to push and will instead be encouraged to listen to your body and go with it by the midwives. If, however, someone did try to coach you unnecessarily or without your permission, your birth partner could step in here and politely ask them to refrain and advocate for you so that your preferences are respected. On that note, I would outline your wishes on your birth preferences document as to how you want to navigate the second stage.
Your down breathing will be a huge help during this stage: a quick inhale through your nose to fill your lungs, then exhaling through your mouth with intent and purpose. Channel your exhale down through your body and feel your muscles respond and move downwards with your breath. Remember to practise this breathing technique on the toilet when going for a poo and get used to the sensation of using your breath as you soften, relax and open to expel something from your body!
It feels like this should be the big finale, but it’s not: there’s still the third stage to follow.
Now on to the ‘third stage’ of labour, or the forgotten stage. It’s easy to assume that once you’ve birthed your baby, the birth is over. But, actually, the third stage is just as important as the previous stages: it is the birth of the placenta – a very important and essential part of the birth process.
So, timing-wise, the third stage begins when baby is born and ends when the placenta is birthed. This is the length of time that will be recorded in your notes. The placenta is usually birthed within an hour of baby being born, but, equally, it can follow just a few minutes after the baby.
This stage is also known as the ‘Golden Hour’ because lots of important and magical things happen in the first hour after birth – not all of them visible to the eye – that offer significant benefits for mother and baby.
The key elements of the Golden Hour usually include:
• Immediate skin-to-skin
• Bonding between mum and baby
• Delayed cord clamping
• Delivery of the placenta
• Control of blood loss
• Establishing breastfeeding
Immediate skin-to-skin means placing the baby on Mum’s chest immediately after birth and then leaving her and baby to enjoy some uninterrupted skin-to-skin time. If all is well and nobody requires immediate assistance, they should have uninterrupted skin-to-skin time for the first hour after birth because it offers so many recognised benefits for both parties. If it’s not possible for Mum to hold the baby for whatever reason, then the baby can enjoy skin-to-skin time with the birth partner. That way, she or he still gets some of the benefits.
Skin-to-skin is recommended best practice after a natural birth and you’ll find this within the NICE guidelines. This isn’t something you should have to request, but just to be sure I always advise stipulating your wishes within your birth preferences document.
Immediate skin-to-skin time, unfortunately, is still not the norm when giving birth in theatre. Times are changing, though, with an increasing number of women requesting natural caesareans, skin-to-skin in theatre is thankfully becoming more common. I’m also aware that in some hospitals there are NHS-endorsed posters actively promoting skin-to-skin in theatre. But even if it’s not the way things are usually done at your hospital or trust, it’s always something you can request. And your wishes ought to be respected – especially if you present them in writing, as part of your birth preferences document. Doctors have a legal obligation to respect your wishes because . . . it’s your body, your baby, your birth and your choice! It’s very possible to have immediate skin-to-skin time in theatre, so long as mother and baby are both well.
The only time it might not be possible to have immediate and uninterrupted skin-to-skin time with your baby after birth is if you or your baby need immediate medical assistance. But in all other cases, skin-to-skin should be encouraged as soon as possible.
If all is well there is also no need for baby to be weighed, cleaned or assessed within the first hour after birth. Paperwork can wait and your baby won’t gain or lose any pounds by deferring the scales for an hour. Likewise, new mums don’t need to be examined, poked, prodded, stitched or washed in the first hour, unless there are urgent medical concerns. Sometimes in a busy labour ward, this Golden Hour can be rushed solely because there’s a conveyor belt that needs to keep running, so you need to make sure you stipulate your wishes in writing and your birth partner advocates for you. Ring-fence this time. It can’t be got back.
The benefits of skin-to-skin time are numerous, but for baby, being placed on Mum’s chest so they can hear her heartbeat offers them comfort and reassurance. Mum’s heartbeat is what they have listened to the entire time they were in the womb, so it’s a very familiar, soothing sound. Skin-to-skin time also initiates the process of bonding for baby.
For Mum, the benefits are even more profound. Immediate skin-to-skin time increases the production of oxytocin, which, as you know, is your happy, feel-good hormone – the ‘love hormone’. Studies have shown that the oxytocin produced at birth helps with bonding, reduces the risk of postnatal depression, reduces the risk of postpartum haemorrhage and increases the success rate of breastfeeding. That’s a pretty good list of evidence-based benefits and the main reasons why skin-to-skin time is promoted at birth and recommended in the NICE guidelines.
Oxytocin, as you already know, is a key hormone when it comes to giving birth and plays the important role of fuelling the surges. At the point of birth, women are meant to get a huge rush of oxytocin, which is why so many women describe feeling euphoric and wanting to do it all again. The evolutionary reason for this great rush of oxytocin is so that you immediately bond with your baby, you feel loving and protective towards him or her, and, as mammals, you don’t abandon your vulnerable off-spring in the wild, leaving them to fend for themselves!
The other function of oxytocin, apart from making you feel all those things, is that it’s the hormone that makes your uterus surge. Even though you have birthed your baby, your uterus muscles still need to work; they need to contract so that the uterus can shrink back down into the pelvis and, by doing so, close off all the open blood vessels where the placenta has detached from the uterus wall, stemming the blood loss. Another evolutionary reason for the oxytocin: we need to stem the blood loss in order to survive and thrive!
So, oxytocin after birth is as important as it was during the earlier stages of labour. Being relaxed enables you to produce oxytocin, so everything that was important in the first and second stages of labour is still important now: maintaining a calm environment, feeling informed and confident, relaxed and positive – not feeling fearful or anxious and producing adrenaline. Use your relaxation techniques when (or if) necessary.
Oxytocin also helps with the production of breastmilk. The huge spike in oxytocin is like a message to your milk-making mammaries to say ‘Baby has been born! Bring on the milk!’ Without the high of oxytocin your breasts may not get the memo. This can cause a delay in your milk coming in and makes getting breastfeeding established more tricky.
All in all, we want loads of oxytocin after birth and skin-toskin with your new baby is the best way of achieving this. You might consider putting your baby to your breast in this Golden Hour because their latching on and stimulating your breast and nipple will help you produce even more oxytocin. Just as nipple stimulation is sometimes recommended in early labour, putting your baby on your breast achieves the same result post-birth.
The next important element to consider in the Golden Hour is cord clamping. This means clamping and cutting the umbilical cord that joins mother and baby. The choice is either to have the cord clamped and cut straight away, known as immediate cord clamping, or leaving it for a period of time, which is known as delayed cord clamping. Delayed cord clamping means the cord is left intact for at least three minutes after the birth. This gives your baby the opportunity to get the majority, if not all, of his or her blood back.
The reason your baby doesn’t have all of his or her blood inside their body at the point of birth is because, whilst your baby is growing inside your womb, at any given point, approximately a third of their blood is in the placenta. The foetal blood moves continually between the placenta and the baby, transferring vital oxygen and nutrients to the baby as it does so. At the point of birth, a third of your baby’s blood is still in the placenta! Of course, we know we wouldn’t feel too great if we were short-changed a third of our blood, and the same goes for our baby – only they can’t tell us how weak and rubbish they feel!
However, by leaving the cord unclamped (delayed cord clamping), the placenta will pump the baby’s blood back down the cord returning it, helpfully, to its rightful owner. If you were to have a look at the umbilical cord after birth, you would see this process happening; at birth the cord will be firm, blue (filled with blood) and pulsing. Leaving the cord unclamped for at least three minutes enables the majority of the baby’s blood to be returned. Opting for fully delayed cord clamping means leaving the cord intact until all the blood has passed through. You will know when this has happened because the cord will be limp, white and visibly empty. This can take up to eight to ten minutes. This might seem like a long time to wait, but, actually, you’ve just given birth! You’re meeting your baby for the first time! Perhaps discovering if they are a boy or a girl! You won’t notice these initial early minutes passing: they slip by quickly in a blur of overwhelming happiness and delight.
The main reason why delayed cord clamping is recommended – and it’s recommended as best practice in the NICE guidelines, which govern NHS practice – is because foetal blood is so rich in goodness. Even though babies who have immediate cord clamping and cutting can and do compensate by making up the volume of their blood over time, the quality of that blood is not the same. Trust that your baby will be just fine if he or she needs to have their cord cut soon after birth – we all probably had our cord cut immediately as that was common practice until recently – but there is evidence to show that it’s beneficial (and indeed advantageous) for baby to have all of his or her blood back where possible. Hence why the NICE guidelines state delayed cord clamping is best practice in natural birth.
The next thing to consider in the Golden Hour is a biggie, and that’s the delivery of the placenta. You have two options: physiological delivery, which means a natural delivery, or active management, which means drugs are used to manage the process.
With a physiological third stage, you birth your baby and wait until all the blood has been pumped back down the cord and returned to the baby (fully delayed cord clamping), you then have the cord clamped and cut, and wait for the placenta to come. Whilst waiting you would be enjoying lovely skin-to-skin time with your newborn baby, taking it all in, revelling in your achievement, so it’s unlikely you’d be watching the clock or feeling that it was taking too long.
Waiting for the placenta can take up to an hour after birth, although it can and, often does, come away of its own accord within the first thirty minutes. After an hour, if there’s no sign of the placenta coming, the midwives would probably suggest changing to active management – introducing drugs to speed up the process – because the placenta does need to come out. It can’t stay in there forever!
If you had given birth in a pool you would be encouraged to step out to birth the placenta on dry land. This is for a number of reasons. Firstly, it’s hard for the midwives to gauge blood loss after birth if you’re in water: the water can turn red quite quickly, even if you’ve only lost a small amount of blood. Secondly, it’s important your new baby doesn’t get cold and if the baby hasn’t got its body in the water then he or she might start to get chilly. Finally, the midwives need to be able to inspect the placenta after birth to check it’s all intact. That means making sure it has come away from the uterus wall as a whole and no parts are left inside you. This is difficult to do if the placenta has been birthed into the pool. So, for all these reasons it might be a good idea to step out of the pool once the cord has been cut and perhaps sit on a birth stool if there is one available, cuddling your baby against your chest with the pair of you wrapped in a towel or blanket. Or you could try sitting on the toilet – a good U.F.O. (upright, forward and open) position which can speed the process up naturally. Or you might like to recline on the sofa if at home (covered in towels/absorbent pads of course!) or the bed if in hospital.
When the placenta does come, you will feel the now-familiar pressure and your body beginning to push. It’s not like birthing another baby. Equally, it doesn’t just slip out unnoticed. Placentas vary in size from woman to woman, baby to baby, but they tend to be approximately an inch or so thick, and if you place the palms of your hands side by side you’ll get an idea of their approximate surface area. So, it’s a sizeable organ, which means your body will need to push (you could always use your down breathing again or give a small push yourself) and you’ll feel it pass through and then – boom! – you’ve birthed the placenta and it’s the end of the third – and final – stage of labour. Congratulations!
What I’ve just described is a physiological third stage where no drugs were introduced and the mother births the placenta naturally. If you’ve had a natural birth, with no intervention, fuelled by your own oxytocin, you’re a lot more likely to have a physiological third stage without complication. Oxytocin – that wondrous hormone – is responsible for the uterus shrinking back down after birth, the placenta separating from the uterus wall and being expelled, and then the uterus continuing to contract down, closing off all the open blood vessels where the placenta came away from the uterus wall. The more oxytocin you have in your body, the better! The more oxytocin, the quicker and more straightforward this stage will be.
Opting for active management changes the pathway of the third stage slightly. With active management you are given a drug to speed up the delivery of the placenta. The drug is given via an injection into your thigh. The cord is usually clamped and cut prior to giving the injection, which can interfere with the delayed cord clamping time. The ideal, if you are opting for active management, would be to reach some middle ground where you get a bit of both; your baby has five minutes of delayed cord clamping and the benefits of receiving the majority of their blood back before the cord is cut and you then have active management, which has been shown to reduce the risk of postpartum haemorrhage. However, if there is a medical reason for why active management is required (for instance, blood loss), this can dictate how long it would be advisable for the cord clamping to be delayed. Obviously, it’s always your choice, but if you are losing too much blood you’re going to want to get that under control and it would take priority. Untreated, excessive blood loss could potentially be life-threatening, as opposed to immediate cord clamping, which is definitely not life-threatening. Delayed cord clamping offers benefits, yes, but if you need immediate cord clamping it’s not dangerous for your baby. It can be dangerous, however, if you’re losing too much blood after birth. I say this not to scare you, but to recognise the need to be open-minded when outlining your preferences: sometimes things have to change slightly (or even a lot) and that’s ok. Understanding why they need to change, opting for what’s best for you and your baby and giving informed consent is hugely empowering.
So, how does active management work and why might you opt for it?
The drug you are given for active management is syntocinon – synthetic oxytocin. Oxytocin, as you know, fuels the surges you experience in labour. After birth, although you don’t want to experience labour surges again, you do want the uterus to contract and shrink back down into your pelvis. Your midwife will check this is happening periodically after birth by placing a hand gently on your abdomen and feeling where the top of your uterus is. As the placenta separates from the uterus wall it leaves a large surface area of open blood vessels, which is where a lot of the blood loss comes from after birth. As the uterus contracts, it closes off these open blood vessels and stems the blood loss. Remember, blood loss after birth is normal and to be expected. Normal blood loss is considered to be between 500ml and one litre. A litre is a significant amount of blood, and yet still considered within the parameters of normal loss.
The quicker the uterus contracts and shrinks, the faster those open blood vessels are sealed closed and the blood flow stemmed. Just like with birth, the uterus muscles are fuelled by oxytocin, so the more of it you have, the more effectively (and faster) the uterus muscles will work. Therefore, giving a woman an injection of syntocinon (synthetic oxytocin) after birth boosts this natural process, speeds up the delivery of the placenta and gets the blood loss under control faster. For this reason, active management is recommended if you are at an increased risk of experiencing a postpartum haemorrhage.
The three most common reasons (in no particular order) women are offered or opt for active management are:
1. To speed up the process: Having the injection is likely to speed up the delivery of the placenta, which you might welcome if you have been in labour for a long time, are exhausted and just want to get into bed with your newborn and a hot cuppa.
2. To get blood loss under control: Giving the mother the injection will help the uterus to contract and shrink quicker, closing off the open blood vessels and stemming blood loss. If your midwife thinks you are losing more blood than expected after birth they will recommend active management.
3. Retained placenta: If you have waited an hour and the placenta is showing no signs of coming of its own accord you will be offered the injection. The injection should kick-start the uterus muscles into action and, by contracting, help the placenta separate from the uterus wall.
So, there we have it! All the stages of labour and, most importantly, what actually happens at each stage. Hopefully, having read this chapter, you now feel a lot more informed about how labour (despite its unpredictable nature) tends to pan out and the key elements you need to consider when creating your own set of birth preferences.
Positive water birth at an attached birth
centre – Sarah, third-time mum
Baby Wilf was born at thirty-nine weeks and is my third baby. My previous two deliveries were less than ideal, which had left me feeling a bit negative about labour if I’m honest. I had pre-eclampsia with one and a failure to progress with the other, leading to two very ‘medical’-feeling births (me on my back, bright lights, lots of bodies, drugs and a total loss of control on my part).
Wilf’s birth could not have been more different and I am still on Cloud Nine about how well it went. I feel the whole delivery was a testament to hypnobirthing. On the morning of the birth I just knew he was on his way and I was excited about what would happen next, rather than anxious. I had my eldest son’s nativity play at the local church at 10am, and by the time I was sitting down listening to him singing I was having light surges every fifteen minutes or so. Back at home, they continued in the same manner for the best part of the day and I chilled out, watching The Holiday, drinking tea and eating biscuits.
At 4pm, I attempted a nap to bank some sleep and help me to relax but found I could no longer sleep through the surges, which were around every ten mins. Then, at 5pm, my waters broke all over the living room floor (proper comedy waters gush like in the movies – it was everywhere). It was at this point that I had a bit of a worry as I realised, with all the excitement over things happening, that I hadn’t felt the baby move for a couple of hours. After phoning triage at the hospital, I was told to come in just to check the baby’s heart rate and, although I had hoped to relax at home for a lot longer to minimise hospital time (my chosen birthplace was the birth centre at the hospital rather than the labour ward), I needed peace of mind, so we loaded the car with the hospital bags and headed off.
His heartrate was fine, but it was at this point that I really feared my birth plan was about to fly out the window as my blood pressure reading was sky high and, given my history of pre-eclampsia, this was a big concern. After consultation with doctors, the midwives told me that the advice was to send me to the labour ward and not the birth centre, and that a water birth was not recommended due to an increased risk of fitting associated with my blood pressure. I asked questions about risks and benefits (needing to change my mindset about ‘not being allowed’ to do things) and, given that I was now having surges every two minutes, asked if it would be possible to get into a pool at the birth centre and reassess my blood pressure there, as I had a feeling that the baby would be making an appearance very soon and feared the labour ward would set me back. The midwives were brilliant and, given that my blood pressure was not yet an emergency situation, they agreed to try it my way for a bit in the hope that the pool would relax me. I was relieved beyond belief and within half an hour I was in the pool.
The next two hours were everything I’d hoped birth would be this time around. My husband, James, put some gentle spa music on, we sprayed the Liquid Yoga room spray and I went into my own zone, focusing on breathing and, lo and behold, my blood pressure went down, hurrah! For an hour and a half, I barely made any noise except to breathe (I can’t tell you how different this was to my second birth, where I swore, shouted and cried!) and I really made use of the visualisation techniques, particularly the hot air balloon one.
James kept offering me water and sweets between surges to keep my strength up and sat by my side the whole time, which definitely made it feel like my safe space. At around 11.25pm I felt like things had changed and that the up breathing was no longer working with me, like something was pushing down into my bottom. I knew it was time to change to the down breaths. Despite having had no internal examinations, my body knew that it was time for him to arrive.
After twenty minutes using the blowing-out-candle breaths, his head was out (again, I felt so calm, stopping to have a chat about the colour of his hair!) and then shortly after, with one final big surge the rest of him followed just before midnight. The cord was wrapped twice around his neck which made me panic momentarily but he was absolutely fine and the midwife helped me to get him onto my chest. The feeling at that point was total euphoria and I felt like superwoman – I have never been prouder of myself, and after two pretty negative births I almost felt like this birth had put the others right somehow. He was 8lb 13oz – my biggest baby yet – but I had paracetamol and codeine only, not even gas and air this time as I just didn’t feel like I wanted them (I’ve sampled all the drugs in previous births and never enjoyed the sensation of being ‘out of it’). Post-birth, things almost got medical again when the placenta got stuck and had to be manually manipulated out by the midwife, but, again, I breathed through it and the atmosphere was not one of panic. After tea and toast, some skin-to-skin and his first feed we left the hospital just a few hours later and were back at home by 5am, meaning our older two had gone to bed like normal and woken up to find a baby brother!
I think the reason this birth was so different was due to the preparation I put in and the resulting conviction I had in my own decisions.