During the first stage of labor, the contractions of the uterine muscles cause the cervix to efface and dilate. (See Figure 6.4.) Effacement refers to the shortening and thinning of the cervix. It is expressed in percentages, from 0 percent (long and thick) to 100 percent (completely thinned out).
Dilation refers to the opening of the cervix. It is measured in centimeters, from 0 centimeters (closed) to 10 centimeters (completely opened). (See Figure 6.5.) Dilation may also be expressed in fingers, with 5 fingers equal to 10 centimeters (approximately 4 inches). Dilation is complete when the cervix has opened wide enough for the baby’s head to pass through into the vagina.
Another term used to measure labor progress is station. Station refers to the location of the baby’s presenting part, usually the head, in relation to the level of ischial spines of the pelvis. (See Figure 6.6.) It indicates the degree of descent of the baby through the pelvis. The station of the baby is expressed in centimeters above (minus) or below (plus) the level of the ischial spines (zero station). The head is usually engaged when it reaches zero station.
Your caregiver or a nurse will determine your progress during labor by vaginal examination. He or she will measure the effacement and dilation of the cervix and determine the station of the baby. Though sometimes uncomfortable, these examinations will help assess your progress.
The first stage of labor is divided into three phases—early, active, and transition. These phases will be discussed individually.
Early labor is the easiest but longest phase of labor. It usually lasts from 2 to 9 hours. Along with effacing, the cervix dilates from 0 to 4 centimeters. Contractions during this phase are from 30 to 60 seconds long. These usually start 15 to 20 minutes apart and get progressively closer until they are about 5 minutes apart. They start out mild to slightly uncomfortable, and become stronger and longer as labor progresses.
- Time your partner's contractions.
- Help your partner determine if it is true labor or prelabor.
- Encourage your partner to sleep if labor begins at night.
- Stop and support your partner during contractions if you are walking with her.
- Remind your partner to urinate every 1 to 2 hours.
- Offer your partner snacks and liquids
- Offer to give your partner a massage or back rub.
- Tell your partner that she is doing great.
During the rest period between contractions, you should feel good, be talkative, and be able to walk around and continue your normal activities. You will probably be at home for most of this phase. Prepared women generally feel very confident during this time and handle the labor well. Some women express anxiety, realizing that once labor has begun, it will not stop.
If labor starts during the day, walk around and keep active to help stimulate the contractions. If labor begins at night, get some sleep or rest so that you can better handle the active phase. Be assured that when your contractions become stronger, you will awaken!
During early labor, you can enjoy sweet liquids such as decaffeinated tea, apply juice, and sports drinks, as well as Jell-O, broth, and Popsicles. Avoid diet beverages, caffeinated beverages, milk, and citrus juices. You may also eat nutritious snacks that are high in carbohydrates and low in fat, such as crackers, fruit, toast, pasta, cereal, and waffles. These foods provide the nourishment needed for labor. In one study, women who were encouraged to eat and drink during labor required less pain relief and less Pitocin, and experienced a shortening of their labor by an average of 90 minutes. Digestion slows during more active labor, and the laboring woman’s desire for food diminishes.
The need of a woman in labor are similar to those of athlete. Prior to an event, an athlete loads up on carbohydrates in order to have the energy supplies that his or her body needs during the event. These needs are similar during labor and especially during the hard physical work of pushing. Fasting while in labor increases the production of ketones in the woman’s system, since her body must use fat stores to supply the body with glucose.
Frequently, IVs are started during labor to prevent dehydration, electrolyte imbalance, and ketosis. Being required to fast is often mentioned by women as a factor that increased their stress during labor. If women were encouraged to simply eat and drink, these negative side effects would be reduced. Permitting women to eat and drink as they desire provides hydration, nutrition, increased comfort, and a feeling of being in control.
Eating during labor remains controversial because of the possibility of vomiting and aspirating the stomach contents into the lungs if general anesthesia is given. On the other hand, general anesthesia is seldom used, and if you vomit while you are awake and alert, you will not have a problem. Aspiration of stomach contents by a woman who fasted can be more serious than by a woman who ate. These contents are highly acidic from the hydrochloric acid that is produced in the stomach. Also, aspiration pneumonia is more common if the woman is given a general anesthetic and not intubated (having a breathing tube inserted into the windpipe) or intubated incorrectly. Current guidelines require that all laboring women be treated as if they had eaten and require the use of techniques to prevent aspiration of stomach contents.
For the Labor Partner: The Labor Partner’s Role in Early Labor
Early labor is the time to become familiar with contractions. If you place your hand on your partner’s abdomen, you can feel the uterus become very hard. Sometimes you can feel a contraction beginning even before your partner is aware of it and can help her prepare for it. Help out by timing the contractions and making sure that your partner is relaxing with them. If you notice her tensing or expressing discomfort during contractions, encourage her to relax, begin slow paced breathing, change position, or urinate. (A full bladder often causes discomfort during labor.) Suggest that she lie in a tub of warm water or take a shower.
- Encourage your partner to take a bath or shower.
- Drive your partner safely to the hospital or birth center.
During active labor, the cervix dilates from 4 to 8 centimeters. After 5 centimeters, labor may progress very rapidly. In fact, labor is more than half over at this point, with the contractions becoming stronger and peaking faster. The peaks also last longer now. The contractions usually last from 45 to 60 seconds and are 2 to 4 minutes apart. If the membranes rupture now, they usually do so with a gush. Many women notice an increase in the intensity of the contractions after the water breaks.
During the active phase, your mood will become serious and very birth-oriented. You may not want to be distracted and may begin to doubt your ability to cope with the contractions. You will no longer want to play cards or games, will be less talkative between contractions, and may need more help in remaining relaxed. You may want to change position or try laboring in a tub or shower.
For the Labor Partner: The Labor Partner’s Role in Active Labor
Continue reassuring and encouraging your partner. It is important to keep her informed of her progress at this time. Help her to maintain control during contractions and assist her with breathing if necessary. She may want to use your eyes as her focal point. Keep your commands to your partner short, since she may not be interested in long conversations. Continue to remind her to empty her bladder ever 1 to 2 hours.
Offer your partner comfort measures as needed. If her mouth is dry, help her sip juice, suck on ice ships or a Popsicle, brush her teeth, or rinse with mouthwash. For dry lips, help her apply lip balm or lip gloss. Wiping her face with a cool cloth may help her feel refreshed. If you are walking with her, you may need to stop and support her during a contraction. If she is in bed, have her change position often, about every 20 to 30 minutes, and help her adjust the bed for comfort. You can start to utilize some of the other tools for labor, such as massage, counterpressure, acupressure, or hot or cold compresses.
- Be positive.
- Encourage your partner to change position.
- Do not leave your partner for any reason.
- Tell your partner that she is wonderful.
- Wipe your partner's face with a cool cloth.
- Offer your partner sips of liquids or ice chips.
- Help your partner apply lip balm to prevent dry lips.
- Try acupressure.
- Stay calm.
- Maintain eye contact with your partner if she becomes confused or panicky.
- Tell your partner that labor is almost over.
- Encourage your partner to breathe evenly and slowly.
- Breathe with your partner if she begins to breathe too rapidly.
- Get your partner to focus on you and to imitate your rate of breathing.
- If your partner feels "tingly," help her to stop hyperventilating by directing her to cup her hands around her mouth and rebreathe the air she exhales.
The transition from the first stage of labor to the second stage is the shortest phase, but it is also the most intense. The cervix dilates from 8 to 10 centimeters. The contractions are usually 60 to 90 seconds in duration and peak very suddenly, possibly more than once. In addition, the contractions may he as close as 1 1/2 to 2 minutes apart. Even though there is a short rest period, some women say that the contractions feel as though they are right on top of one another with no relief. Transition may last 10 minutes to 1 1/2 hours. Think positive—labor is almost over!
Certain signs will alert you and your labor partner to the fact that you are in transition. These signs, which you may or may not experience, are:
□ Premature urge to push or bear down. You may mistakenly think that you need to have a bowel movement.
□ Belching or hiccups.
□ Nausea and/or vomiting.
□ Shaking or uncontrollable trembling of your legs or body.
□ Chills and/or extreme warmth.
□ Loss of modesty. You may throw off your covers.
□ Cramps in your legs and buttocks.
□ Sensitivity to touch. You may not want to be touched.
□ Spontaneous rupture of the membranes now if it did not yet happen. At this point, it usually happens with a gush.
□ Dopey feeling, amnesia between contractions, or sleeping between contractions. This is probably caused by the release of endorphins.
□ Increased bloody mucous discharge.
□ Confusion and/or a tendency to give up. You may say, “I can’t do it,” or “I can’t take another contraction.”
□ Feeling of getting nowhere, that labor will never end.
□ Panic if left alone.
□ Susceptibility to suggestion, especially if offered medication.
□ Inability to comprehend direction and a need for your labor partner to do the breathing patterns with you.
□ Irritability and restlessness.
□ Feeling of being out of control. You may feel overwhelmed by the contractions.
□ Flushed face.
Be assured That you will not experience all of these signs.
For the Labor Partner: The Labor Partner’s Role in Transition
During transition, your encouragement and presence are vital. Do not leave your partner during this time for any reason. She may panic if left alone, even for a short period. She may more than likely accept any medication that is offered or may possibly ask for medication, even though her decision was not to use drugs. Remind her that she is in transition and any medication taken at this time may not take effect until the phase is over. However, any drugs taken now might have a strong effect on the baby. An epidural may not begin to provide relief until the pushing stage, at which time she will need to be able to feel the sensations to push effectively. Many women find that relaxing in water during transition provides sufficient pain relief to avoid the need for medication.
If your partner says that she needs to move her bowels or begins to bear down, inform the nurse so that an examination can be performed. If the cervix is not fully dilated but is stretchy, the nurse may instruct the woman to bear down with the contraction to see if the cervix will open completely. But if the cervix is unyielding and tight around the baby’s head, pushing will only cause exhaustion. In this case, you will have to instruct your partner to blow out forcefully during the urge to push.
You must make sure during transition that your partner “catches” each contraction. If she sleeps or has amnesia between contractions, you must make sure that she starts her breathing pattern in time. Let her know when the contraction ends and help her to relax in between. Remain calm. Even if your partner yells at you, do not argue. Make your commands short and precise. If your partner becomes confused, have her sit up in bed.
If your partner says that she wants to give up, keep reminding her that this is the shortest phase and that labor is almost over. Occasionally, a woman will want to squeeze something. Be careful what you offer her! If her fingernails are long, they may dig into your skin. Give her a pillow to hold. Offer her two fingers to grasp, rather than your full hand, especially if you wear a ring.
For the Labor Partner: What Should I do If She Panics?
You may notice that your partner is not using a focal point, is rocking her head from side to side, or is gripping the bed sheet, your hand, or a bed rail. She may stop her breathing pattern and bold her breath, yell, or cry out. She may even thrash around in the bed. Your partner is panicking. To help her regain control, you should first stand up. This puts you in an authority position. Grasp her face or wrists with your hands and call her name. Bring your face close to hers and do the breathing pattern with her. If she is vocal, encourage low moaning, but direct high squeals to a lower octave. You may need to be firm with her during this time and take full command of the situation. Generally, when the contractions become unbearable, transition is almost over, with just a few contractions left. Be sure to ؛ell your partner this.
Continue with the other comfort measures as needed. If your partner’s back is uncomfortable, perform counterpressure or acupressure, massage the area, or apply a warm or cool cloth. If her feet are cold, put warm socks on them. If her legs are trembling, firmly massage her inner thighs or grasp her legs. Keep a cool cloth on her forehead or neck if she is nauseated. Tell her she is doing wonderfully and keep her informed of her progress. Above all else, keep a positive attitude!