The Stages of Labour and Birth

First stage: latent, then established

The first stage is really two things wearing one name. NICE splits them: the latent first stage is when there are contractions and "some cervical change, including cervical position, consistency, effacement and dilatation up to 4 cm"; the established first stage is when "there are regular contractions and there is progressive cervical dilatation from 4 cm."

The NHS puts the target plainly: "your cervix needs to open about 10cm for your baby to pass through it. This is what's called being fully dilated."

How long the first stage takes

NICE gives figures for the established part only, which is why they look shorter than most people's lived experience: "first labours last on average 8 hours and are unlikely to last over 18 hours"; "second and subsequent labours last on average 5 hours and are unlikely to last over 12 hours." The NHS quotes the same range as 8 to 18 hours for a first pregnancy and around 5 to 12 hours for a second or third.

Ireland's HSE describes the whole process rather than the established stage, and lands on "most first babies arrive after 12 to 20 hours". Both are correct; they are measuring from different starting lines.

Monitoring in the first stage

The NHS describes the default: a small handheld device used to listen to your baby's heart every 15 minutes, with you "free to move around as much as you want." Electronic monitoring — two pads strapped to your bump, one for contractions and one for the baby's heartbeat — is suggested if there are concerns, or if you choose to have an epidural. Sometimes a foetal scalp electrode is used instead for a more accurate measurement.

Two things the NHS says that are worth holding on to. You can ask for electronic monitoring even if there are no concerns, though it "can sometimes restrict how much you can move around." And if you were put on monitoring because of a concern about the baby's heartbeat and the heartbeat is shown to be normal, you can take the monitor off.

Vaginal examinations are offered, not imposed. The NHS: "if you do not want to have these, you do not have to — your midwife can discuss with you why she's offering them." NICE's default frequency in the first stage is four-hourly, or sooner in response to your wishes or if there is concern about progress.

If the first stage slows

The NHS names the two interventions usually discussed: breaking your waters, and an oxytocin drip. Breaking the membrane, formally artificial rupture of the membranes, is done during a vaginal examination and "may make your contractions feel stronger and more painful". NICE advises that it "will shorten labour by about an hour". If that does not work, synthetic oxytocin can be given through a drip; NICE says the dose should be increased no more often than every 30 minutes, "until there are 3 to 4 contractions in 10 minutes". Oxytocin brings continuous electronic monitoring with it.

NICE's counterweight is worth quoting: "do not offer or advise clinical intervention if labour is progressing with no complications or concerns and the woman or pregnant person and baby are well." And separately: "do not routinely perform amniotomy if labour is progressing with no complications or concerns."

Second stage: full dilatation to birth

NICE splits this one too. The passive second stage is full dilatation before or without active pushing. The active second stage begins when the baby is visible, or when there is involuntary or active pushing with the cervix fully dilated.

That distinction is not academic. If you have an epidural you may not feel an urge to push at all, and NICE allows a passive second stage of up to 2 hours before pushing starts, because delayed pushing "may shorten the active second stage of labour."

How long pushing should take

NICE sets expectations by parity and epidural status. Without an epidural, for a first baby, "birth would be expected to take place within 3 hours of the start of the active second stage in most women", with reassessment after 1 hour of active pushing and senior review if birth is not imminent after 2 hours. For a second or later baby, the expectation is within 2 hours, with reassessment at 30 minutes and senior review at 1 hour.

The NHS gives the same outer limits in patient language: "if you're having your 1st baby, this pushing stage should last no longer than 3 hours. If you've had a baby before, it should take no more than 2 hours."

Position and the birth itself

The NHS lists sitting, lying on your side, standing, kneeling and squatting, and suggests kneeling on all fours if you have had a lot of back pain in labour. As the head crowns, "your midwife will ask you to stop pushing and take some short breaths, blowing them out through your mouth" — the point being to let the head be born slowly so the perineum has time to stretch.

Once the head is born, the NHS says the rest of the body "is usually born during the next 1 or 2 contractions". You will usually be able to hold your baby immediately, and ideally the first feed happens within an hour of birth.

Third stage: delivering the placenta

This is the stage most people do not realise involves a choice. NICE defines the third stage as "the time from the birth of the baby to the expulsion of the placenta and membranes", and expects the two options to be discussed with you antenatally, at your initial assessment, and in labour.

Active management is a package: routine uterotonic drugs, cord clamping and cutting, and controlled cord traction after the placenta separates. The NHS describes it as an oxytocin injection into your thigh as you give birth or soon after, with the cord clamped between 1 and 5 minutes rather than immediately, and the placenta usually delivered within 30 minutes.

Physiological management is the same package removed: no routine uterotonic drugs, no cord clamping until pulsation has stopped, and delivery of the placenta spontaneously or by your own effort. The NHS notes the cord usually stops pulsing after around 2 to 4 minutes, and that it "can take up to an hour for the placenta to come away".

The numbers behind the choice

NICE publishes the comparison. With active management about 68 women per 1,000 would be expected to have a haemorrhage of more than 500 mL, against about 188 per 1,000 with physiological management. For a haemorrhage of more than 1 litre the figures are about 13 per 1,000 versus about 29 per 1,000, and for needing a blood transfusion about 13 per 1,000 versus about 35 per 1,000. The trade-off is real too: about 186 women per 1,000 would be expected to have side effects such as nausea, vomiting and headache with active management, against about 90 per 1,000 with physiological management.

NICE's summary recommendation is that "active management of the third stage of labour is associated with a lower risk of a postpartum haemorrhage or blood transfusion." The NHS adds that there are situations where physiological management is not advisable, and that you can switch to active management at any point during the third stage — including if the placenta does not come away or you begin to bleed heavily.