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​Labour is traditionally divided into three stages: 

  • Stage 1 — process of dilatation of the cervix which is divided into: a) Latent phase — dilatation and thinning of the cervix to 3 cm b) Active phase — continued dilatation and thinning of the cervix from 3 to 10 cm (full dilation = 10 cm) 
  • Stage 2 — delivery of the baby after full dilatation 
  • Stage 3 — delivery of the placenta​ 

The length of labour​ varies for different women. The average active phase of labour lasts for 8–12 hours in your first pregnancy. Labour is often shorter for subsequent pregnancies. 

Stage 1 — Latent Phase 

Duration: variable, from a few hours to a few days.

This is often the least painful stage of the labour. During this phase, you may experience very non-specific symptoms such as a mild backache, abdominal cramps, bloody show or passing of the mucous plug. Ambulation can help by distracting you from these symptoms and hasten this phase. You may start to prepare to head for the hospital once the contractions increase or if your water bag bursts. ​


Stage 1 — Active Phase 

Duration: 8–12 hours (about 1 cm per hour of dilatation). 

During this phase, the contractions increase in intensity and frequency, lasting for up to 45 seconds at times. By this time, you should have been in the hospital for an internal vaginal examination to assess the extent of cervical dilatation. You would have been admitted into the delivery suite for the management of this phase of labour. 

It is a common practice to manage your labour actively. This entails artificially rupturing your membranes and getting you started on an intravenous medication known as oxytocin to maximize your contractions. Studies have shown that this shortens the labouring process and thus avoids the problems associated with a prolonged labour, such as infections and post-delivery bleeding. 

Furthermore, the rupture of the membranes enables your doctor to assess the colou​r of the liquor to see if meconium (motion) has been passed out by your baby, which may indicate that your baby is under stress. Be assured that there is nothing unnatural about this as it merely serves to assist your natural delivery process. Furthermore, it does not increase your chance of having a cesarean section

You will also be offered a variety of pain relief options (read the article on Labour Pain Relief​).

Stage 2 — Delivery of Your Baby 

Duration: 30–120 minutes (this may be longer if the clinical situation allows, especially if epidural anesthesia is used). 

This is the stage where you are required to work the hardest to help push your baby out. Your doctor and/or the midwives will be beside you to help guide you​ through this. You may notice an urge to bear down owing to the pressure of the baby’s head on your perineum and back passage. This may be accompanied by the passage of faeces but do not be embarrassed. To aid the delivery, your legs may be raised up to allow more room within your birth canal. It is also here that an episiotomy may be made for the delivery (read the article on Pushing and delivery: Is an episiotomy needed?)

At times, your obstetrician may even need to assist you by using either a vacuum, forceps device or even fundal pressure to help deliver the baby’s head (read the article on Vacuum and Forceps delivery​). 

​Stage 3 — Delivery of the Placenta 

Duration: 5–30 minutes.​  ​

Once the baby is delivered, your uterus will continue to squeeze out the placenta so that it separates from the wall of the uterus (Figure 35.2). 

This separation process is usually accompanied by a sudden gush of blood from your vagina. Prior to this, the baby’s cord blood will be collected. You can help at this stage by remaining patient while your episiotomy or vaginal tear is being repaired. 

In almost all the cases, we do actively manage your third stage of labour. This includes administering an intramuscular injection of an oxytocic after the delivery of your baby, followed by the delivery of the placenta through a controlled cord traction technique. Again, this has been found to reduce the incidence of post-delivery bleeding. 

Rarely, separation does not occur and this results in a retained placenta. In addition to causing discomfort, it can also give rise to increased bleeding. Under these circumstances, it may be wise to have your doctor remove it manually by inserting his hand into your womb through the vagina under a general or regional anesthesia (manual removal of placenta). 

Some patients may opt to claim back the placenta for personal or religious reasons. For others, the hospital would dispose of it in an appropriate manner. 

Possible Immediate Problems Following Vaginal Delivery 

Immediately after a seemingly uneventful vaginal delivery, some common problems may arise in the immediate postnatal period. These include: ​

  • Excessive bleeding due to​ a poorly contracted womb — requiring additional medication to help contract the womb muscles. You will stay in the delivery suite for a longer period of time after delivery to allow us to monitor you more closely. 
  • Vaginal tears — requiring meticulous repair, sometimes even in the operating theater. 
  • Retained placenta due to a failure of the placenta to separate spontaneously — requiring a manual removal under anesthesia, whereby the doctor has to insert his/her hand through the cervix to remove the placenta. 
  • Vulva swellings — in cases of edema, simple icing is sufficient. In cases of hematomas (blood clots), surgical drainage in the operating theater may be required. 
  • Delayed profuse vaginal bleeding due to remnants of placenta tissue retained — in most cases, this may happen even if the initial inspection of the placenta at the time of delivery had been completed. However, it has been well documented that despite precautionary measures, small remnants of the placenta may still be left behind causing heavy bleeding. Treatment requires admission, administration of antibiotics and medications to help the womb contract. In some cases, an emergency cleansing of the womb may be done in the operating theater. 
  • Fever (pyrexia) — this may be due to urinary tract infection, breast problems (like engorgement, mastitis or abscess), wound/womb infections or rarely blood clots in the lower limbs (“economy class syndrome” or deep vein thrombosis). Appropriate investigations must be carried out so that appropriate prompt treatment can be given. 

​Birthing Positions 

Do the different birthing positions like on all fours, squatting and birth stools help in the delivery?​

  • Semi-recumbent positionMost women deliver in the conventional semi-recumbent position in KK Hospital. This is a position, which is comfortable for the labouring mothers, especially for those on epidural analgesia. This position also allows the obstetrician to have good visualization of the baby’s head position and ease of intervention like forceps or vacuum assisted ​delivery should the need arise. There is also​ the rare complication of the baby’s shoulder being stuck in the birth canal (shoulder dystocia) after his/her head is delivered. This life-threatening emergency needs the obstetrician to perform mano​euvers to​ save the baby and the semi-recumbent position is best for such manoeuvers. 
  • “All fours” position - this position, which is kneeling in bed and leaning forward with support, may help to relieve the back pain when the baby is in an occiput posterior (face up) position (OP) and may also facilitate rotation of the baby’s head from OP to occiput anterior (face down) position. Some women use birth balls (of 55–75 cm in diameter) to help them get into the position. 
  • Squatting position - Some mothers may prefer to deliver in the squatting position as gravity might assist the delivery process. The use of a birthing chair or stool is recommended for giving birth in a squatting position. However, using a birthing chair has its drawbacks. It may cause excessive tearing of the perineum. This happens when the baby’s head puts extra pressure on the perineum. While the tear is not a serious problem, it might lead to more discomfort and a longer healing time. 

Unfortunately, there have not been conclusive studies to look into the advantages and risks of the different birthing positions. Thus, it is important to discuss your birth plan and communicate your desired birthing position with your obstetrician so that preparation can be made when you are admitted to the delivery suite. This discussion should commence before you reach term (i.e. 37 weeks of pregnancy). 

Water Birth 

This concept of delivery involves the labouring mother sitting in a warm tub of water in an attempt to reduce the pain and discomforts of labour in a more “natural” way. Some women who had opted for this have found it a more satisfying method of delivery. 

However, there are certain disadvantages associated with it. Some of the hospitals are not equipped with the facilities to support such a birth. Monitoring of the baby’s condition becomes difficult with the mum submerged in the water. Infections may also occur as the water is contaminated with urine and faeces. Owing to the warmth of the water, blood loss may be greater after the delivery of the placenta. Great care must be practised to remove the baby from the water immediately after the delivery to reduce other complications.​ 

​You should speak to your obstetrician in greater detail if you have any queries over this. ​

Frequently Asked Questions 

1. What is engagement? When do primips/multips usually engage? 

Engagement is the movement of your baby’s head into the pelvis. It occurs at the end of your pregnancy. Your baby is considered engaged when the head has descended below the pelvic bone. In primips (first time mothers), engagement typically occurs before labour. In multips (those who have delivered before), the baby may not engage until the start of labour. During engagement, your abdomen may seem smaller as the baby enters your birth canal. You may also feel some aches or heaviness in your pelvic joints and perineum as well. 

2. When does a baby’s head usually turn down? If the head is down, will it turn again? 

In most pregnancies, babies are born head first. This means that most would have turned to a head down position by 37 weeks. In only 3% to 4% of cases, the babies are found to be breech at time of delivery. After 37 weeks, if the baby is still not in a head down position, it is very unlikely that the baby would turn spontaneously. 

In some cases, there may be frequent changing of fetal lie and presentation after 36 weeks. This is termed as an unstable lie. 

Common causes of unstable lie include:

  1. High parity (delivered more than once before) 
  2. Low-lying placenta (Placenta previa) 
  3. Excess liquor (Polyhydramnios) 
  4. Structural womb abnormalities 
  5. Fetal abnormalities (e.g. tumors of the neck) 

In such situations, your obstetrician will need to assess you properly and decide on the best mode of delivery. 

Acknowledgement

Source: Dr TAN Thiam Chye, Dr TAN Kim Teng, Dr TAN Heng Hao, Dr TEE Chee Seng John, The New Art and Science of Pregnancy and Childbirth, World Scientific 2008.