The Divided Tale of the Stages of Labor: The First Stage

“Stages of labor” is what is taught when dividing labor into pieces using a cervix centered model of assessment.  I find it is useful to know this story as it can affect what people decide to see in another’s birth.  It can affect how birth stories are told.  It can affect what information is collected and recorded.  

Once upon a time, there were 4 stages of labor.  However, this blog is only about the first stage. 

One night a particular person with a large pregnant belly woke up and realized that they were having contractions every 10 minutes.  They went back to bed and woke up the next morning without contractions and still pregnant.  Now, the cervix might have opened a little and the baby might have come further into the pelvis, but as the contractions didn’t continue, the next day they went about as planned.  That night after sleeping for a good three hours, they, again, woke to find contractions were coming every 4 minutes but this time they were stronger.  The intensity was coming in waves and although one could talk between them, there was a pause at their peak.  The contractions seemed to pick up and become more rhythmic.  Privacy became important.  The intensity picked up and the body began to move as if on its own.  In fact, fairly quickly there was a catch in the birthing moans.  That catch would be present for a few contractions in a row and then be gone for a little while just to return with more force.  One could see the spreading of the lower back and buttocks slowly changed shape and the toes began to angle in as the sounds of pushing filled the air.   

Now, is this person in the first stage of labor? Oops, wait, that was a different story.  No one was checking the cervix.   

The story of the first stage of labor is one of consistent contractions and an opening cervix and of lots of generalizations (we will do the best we can do with it).  The cervix starts out long and hard kind of like your nose. Yes, go ahead.  Feel your nose!   …..I’ll wait for you to do that…..   Then, in this particular story, the cervix begins to thin and be more like the inside of your lips puckered.  Go ahead, I’ll wait, feel that too……..  You feel the tube?  softer, eh?  What does it feel like?  It is now softening and opening and thinning out which is called effacement.  And soon that same cervix feels like your lips at rest but also opening.  It begins to get thinner and thinner.  Paper thin.  and then melts away like butter.  But it doesn’t melt away because it comes back.  As the cervix opens and dilates more and more, one goes from possibly 3 cm to 5 cm to 7 cm and then we begin to see what is left of the cervix.  1 cm left makes it a 9 cm cervix.  See, numbers can assume everyone has a 10 cm cervix.  Some of you out there may be walking around with 13 cm cervixes and others 9!  Once that cervix is gone, one could be said they are done with that first stage of labor.  

When does one truly cross over from that first stage?  How do you define that ending?  If a tree falls in the forest and no one hears it,  does it make a sound? 

The first stage can also be divided into early labor, active labor, and transition.  Early labor is when you live your life and you have this laboring thing happening on the side.  Maybe you go to Thai food in early labor and you talk and eat and pause during the contractions, maybe you go to the beach to watch the waves roll into the shore.  Suddenly there is a shift and the laboring thing is really the main focus and the eat, drink, pee, poo thing is on the side.  If you weren’t already home (or wherever you are birthing), you go there.  Soon there is a building of intensity and the contractions get longer and more intense.  Yet transition is where one enters labor land and goes deep, deep,  …… deeper within.  The Fergusson Reflex influences the release of hormones as the baby comes down upon the cervix.  Maybe the cervical capillaries begin to burst and little bits of blood or bloody show (a mixture of blood and mucous) appears.  You sleep between the contractions and when they do come, your breathing begins to change before a possible jolt to wake.  Changing position can be useful and intense.  

But how does one know when they are done with this stage?  Is it the catch in the voice that signals early 2nd stage?  Is it when a provider tells them to push?  Is it when they need to poop so badly and nothing comes out?  Like all stages, it comes to an end.  Somewhere.  Somehow.  Whether recorded or not.  

And I need to be honest.  Sometimes the first stage doesn’t look like this at all.  There is a Spectrum of Ease for birth.  Labors with a little bit of activity and then 5 strong contractions and the urge to push.  Labors that last several days.  Some of it prodromal with asymmetrical labor patterns that don’t find that traction or consistency or intensity but interrupts sleep.  Maybe someone helps with balance, positioning, feeding them, and patience.  Maybe someone helps with other tools including interventions to be able to move through this stage of labor.  But whatever the case, that cervix in that first stage softens, thins, opens.  This tale is based on that cervix. 

The vaginal exam of the cervix is the assessment in an obstetrical model.  But we can see and feel and hear birth as well.  That cervix is connected to our nervous system and movements and anatomy.  It is connected to the flow of the body and is in relationship with the uterus which is encasing this baby.   

The Divided Tale of the Stages of Labor:  The Second Stage

When we left off, our birthing parent was just starting to feel, sound, and look a little bit different.

But as we are talking about the tale of the cervix and the second stage, what happens next is that the person about to birth pushes out the baby.  And that is it.    

Any questions?

Because that is the Tale of Labor for the second stage, but I will add a little bit more for inquiring minds.

There is a sometimes an unacknowledged experience of an early, active and transition for the 2nd stage.  It is similar to that of the 1st stage, and this time the early might actually overlap with the 1st stage.  That line of delineation is quite subtle and sometimes unknown. Last post we were discussing that early part of second stage can be defined by a little grunt or catch in the voice.  It can be defined by this catch that wakes the birth workers up in the room.  Sure just a moment ago they were asleep lulled by the sounds of laboring, but suddenly, they are attentive to this second stage.  They are entraining to the person who is birthing.  That waking is the surge of good adrenaline that can sometimes bring one back from labor land where feet are on the ground or hands are grasping while in the tub.  The wake up call can come all at once… or slowly.

And the early pushing may be just hints of an urge.  The changing shape of a rear end.  A purple line extended as the sacrum is pushed out into a bulge increasing in length.  Sometimes there is a need to escape the pressure or the feeling that the contraction never ends.  An urge to poo and a person heads over to the toilet.  Sometimes it is poo and other time there is a lack of bowel movement, but the urge is only at the height of the contraction.  Soon, the pressure is increased, and the bearing down from the small catch becomes longer and longer until it sustains.  You can hear it out in the driveway at night and you know the time of the transition is near.  The house is shaking along with the soul about to enter.   

Its nearing transition to earthside.  And we are here.  Awake, Aware.  The dance of the constellation of the family and the attendants or friends continues.  The baby might be seen little by little if one happens to be looking.  It is as if rolling out cookie dough as the head  (or bum) begins to rock, back and forth.  Seeing just a little and then disappearing.  One might wonder if they were seeing the baby at all.  Back and forth, back and forth.  The baby releases muscles and tissue and fascia.  Space expands in ways one might think impossible.   More and more becomes visible until we are just about at that place of crowning.  It is the place of transition between one stage and the next.  It is the birth that we await.  The pacing may slow as there may be a tentative edge from within to protect the tissues …  or maybe not.  Maybe with a large push and decision to be done with this, the baby’s head completely emerges.

Pause.

Wait for the next contraction.

Notice that the scrunched face is draining fluids as it begins to rotate and is aligned with the shoulders from within.  We are so close.  A release.  It’s not over this transition.  For someone or no one will catch this baby as it comes to this world to be welcomed. The good adrenaline will now be accompanied by the highest amount of oxytocin in the third stage.  But that is another story.

And we also know that this is a generalization.  That some people birth so quickly that they barely catch their own baby while alone.  Some people are pushing for 3 hours or 5 hours or more until transitioning earthside.  This work can also involve interventions like a vacuum or forceps or even hands that help a shoulder rotate and release.

And when does that stage of birth end?  A specific time of birth is definite.  But it is also the birth of a family and a new relationship.  Maybe it truly ends when one picks up their baby?  Or maybe it is when the baby born in the water seems to wake with awareness.  Maybe the baby is on a threshold between two worlds and breathing through the umbilical cord and at the same time just about to take their first breath of air.

One can look around at all the people holding their breath.  It is sometimes the baby who is the role model and breathes for them.      

The Divided Tale of the Stages of Labor:  The Third Stage

Once upon a time, a baby was born and in that very moment, the third stage began.  Just. like. that.  This story is born in that very moment until the birth of the placenta, but that isn’t the whole, entire story.  As you may have noticed, there is usually more to a story than meets the eye or ear.

The tale of the third stage is usually a short tale, but today we will visit a different version of it that includes early, active and transition.  It is also one that is woven with the Three Fates of the past, the present, and the future.  We also know that the Tales of the Hormones of Labor will be woven from that same fabric.  It is at this time we truly respect the highest levels of oxytocin of one’s entire life.     

Baby has just come up to the chest and is now looking around and is truly on the threshold. Welcome, baby.  Early first stage may not look like much is happening but the world has changed forever with the birth of a family.  The baby may look around and meet the eyes of its parents.  The parents gaze back.  And it is in this specific moment that we watch the unfoldment.  As midwives, we know how the baby is doing by listening and watching.  Much of the time there is no need to listen with the stethoscope.   We can see the color, tone, flexion of the baby as it may or may not have its eyes open.  We can sometimes even see the arrhythmic breath.  Maybe there is a burst of noise as the baby cries or a softness of the breath with a sneeze.

The parent who has birthed typically responds to baby, although sometimes baby has come quickly or the birth was overwhelming and a pause is in order.  A regathering.  Maybe it is a surprise how this time feels.  This looks different for so many, but these moments of connection are raising levels of oxytocin that can provide contractions to bring the placenta.   The contractions that are created from this love hormone may or may not be felt.  This is the active third stage.   

Little spiral vessels under the placenta corkscrew and the placenta begins to sheer off of the wall of the uterus typically under the weight of a clot that forms behind.  Typically a gush of blood called the separation gush signals that the placenta is soon arriving.  It slides down and sometimes can feel quite uncomfortable until born.  There are no bones.  It is much smaller than the baby.  It is when it is born either spontaneously with or without pushing efforts or with gravity or cord traction or even a scoop of the hand that we can truly say that the third stage is over.  Although the hormonal interaction is lingering.  The cord in many cases has remained connected to the baby.

The 4th Stage is that of the hours following and stabilizing blood loss.  I think often about how I’m in the 120th stage with my 13 year old.  So many transitions in life.

Buckley, Sarah.  Hormonal Physiology of Childbearing:  Evidence and Implications for Women Babies and Maternity Care.  Washington DC, Childbirth Connection, June 2015.

England, Pam.  Advanced Birthing from Within Training 2005, Exercise “The Unfoldment”  Walnut Creek

#cervixcentric #stagesoflabor #shifttheparadigm #talesofbirthreframed