The first stage: early and active labour

The first stage of labour is the longest part: the work of opening the cervix so your baby can leave the uterus and move into the birth canal. It begins with the early (latent) phase described in "How labour starts" and continues through active labour until the cervix is fully open. This chapter explains what your body is doing, how long it takes, what happens when you arrive, and how to help labour along.

What the cervix does

The cervix is the neck of the uterus, the passage between the uterus and the vagina. In pregnancy it is long, firm and closed, a little like the tip of your nose. In labour it changes in three ways.

It softens and moves forward. In late pregnancy and prelabour it becomes softer, more like your lips, and shifts from pointing toward your back to pointing forward.

It thins out (effacement). It starts about 3 to 4 cm long and gradually draws up into the wall of the uterus until it is paper thin. This is described as a percentage (50 % effaced, 100 % effaced) or in centimetres of length left.

It opens (dilation). The opening widens from closed to about 10 cm, roughly the width of your baby's head. At 10 cm the cervix is "fully dilated".

With a first baby the cervix usually thins first and then opens. With later babies both often happen together, one reason later labours tend to be quicker. Each contraction pulls the cervix up and open a little while pressing your baby's head down onto it. Between contractions the muscle relaxes and your baby gets a fresh supply of oxygen.

How long it takes

Every labour is its own, and the ranges are wide. Most care providers today count active labour from about 5 or 6 cm, rather than the 3 or 4 cm used in the past, because many labours move slowly until then and that is normal. Phase First baby Later babies

The old rule that the cervix should open 1 cm an hour is no longer used. Many healthy labours go more slowly, especially before 6 cm, and some go in bursts, with long plateaus followed by fast change. Your team will look at the overall picture over several hours. If labour is slow, "When labour needs help" explains the options.

What contractions feel like

People describe strong period cramps, a tight band around the belly and back, or a wave that builds, peaks and fades. The belly goes hard during a contraction and soft afterwards.

In early labour, contractions may be 10 to 20 minutes apart and last 30 to 45 seconds, and you can usually talk through them. In active labour they usually come every 2 to 4 minutes and last about a minute, and you need to stop and breathe through each one.

Even at the most intense point, most of the time is spent between contractions. Take each one as it comes and rest fully in between.

Arriving and being assessed

When you arrive, a nurse or midwife will assess you, sometimes in a triage area before you are given a room. They will ask when contractions started, how often they come, whether your waters have broken, whether you have bled, and how your baby has been moving. They will read your notes and birth preferences, check your temperature, pulse, blood pressure and urine, feel your belly for your baby's position and the strength of contractions, listen to your baby's heartbeat, and offer a vaginal examination. If you are in active labour, you will be admitted. If you are in early labour and all is well, you may be offered the choice to go home for a while (see "How labour starts"). Tell them how you are coping, not just how often contractions come.

Vaginal examinations

A vaginal examination checks how open and thin your cervix is, where your baby's head is and which way it faces, and whether your waters have broken. Your midwife or doctor puts two gloved fingers into your vagina, usually between contractions, for a minute or two. Exams are commonly offered on arrival and about every 4 hours in active labour, or more often if there is a reason, such as before pain relief or if you feel an urge to push. You can ask to stay in a more comfortable position than lying on your back, ask them to stop at any point, and ask what they found.

A vaginal examination always needs your consent. You have the right to decline one or to ask for fewer, and progress can also be judged by your contractions, how you sound and behave, and where you feel pain. It is reasonable to ask "What will the result change?" first. An exam is a snapshot, not a prediction: someone at 4 cm may have their baby two hours later, and someone at 7 cm may take much longer.

Monitoring your baby's heart rate

Your baby's heart rate shows how your baby is managing labour. It is typically about 110 to 160 beats a minute, with small, constant variations and changes around contractions.

Intermittent listening

If you and your baby are healthy and labour is straightforward, the recommended approach is intermittent auscultation: listening at regular intervals with a handheld Doppler or a special stethoscope, commonly about every 15 to 30 minutes in active labour for a minute after a contraction, and more often when pushing. You can move freely and use a bath or shower; many devices are waterproof.

Continuous monitoring (CTG)

Continuous electronic fetal monitoring, or CTG (cardiotocograph), uses two soft belts around your belly, one for your baby's heart rate and one for your contractions, shown on a screen or paper strip. It is usually recommended with an epidural or oxytocin drip, a medical condition, a preterm or small baby, meconium in the waters, a fever, or if intermittent listening picks up something that needs a closer look. In healthy, low-risk labours, routine continuous monitoring has not been shown to improve outcomes for babies and leads to more caesareans and assisted births, which is why it is not used for everyone.

Continuous monitoring does not mean lying on your back. Many units have wireless monitors, and you can sit on a ball, stand or kneel with the belts on. If the belts struggle to pick up the heartbeat, a small clip called a fetal scalp electrode may be placed on your baby's head, with your consent.

Eating, drinking and emptying your bladder

For most people in straightforward labour, light food and drinking to thirst are now encouraged. Labour is hard physical work. Water, juice, sports drinks, broth, toast, crackers, fruit and yogurt are good choices. Many people lose their appetite in active labour; sips of fluid after each contraction are enough. With an epidural, an opioid, or a higher chance of needing a general anesthetic, your team may suggest clear fluids only.

A full bladder takes up room your baby needs, can slow labour, and can be harmed by prolonged pressure. Try to pee every hour or two, even without the urge. With an epidural, a nurse may empty your bladder with a thin tube called a catheter.

Positions and movement

Moving around and staying upright in the first stage is linked to a slightly shorter labour, fewer epidurals and fewer caesareans compared with lying on your back. Gravity helps, the pelvis can shift and widen, and contractions often work better. Change position every half hour or so and let your body guide you:

Walking, swaying, or slow dancing with your partner.

Standing and leaning forward on a counter, the raised bed or your partner. Sitting on a birth ball and circling your hips.

Kneeling over a ball, or on hands and knees, especially for back pain. Side-lying with a pillow or peanut ball between your knees to rest, including with an epidural.

Sitting backwards on a chair, or on the toilet.

A warm shower on your lower back or a deep bath can ease pain and help you relax. "Coping with pain without medicine" covers this and much more.

The birth room environment

Your surroundings affect your hormones and how you cope, and you can shape the room more than you might think. Dim the lights, close the door and curtains, bring a pillow from home, play music or ask for quiet. Ask that people knock and keep conversation low. Feeling safe and unobserved helps oxytocin flow.

Shift changes

Labour often outlasts a nursing or midwifery shift, so you may meet new staff partway through. A good handover happens at or near the bedside, and the new person should introduce themselves and know your preferences. Your support person can tell the new person what has been helping.

IV lines

An intravenous (IV) line is a thin plastic tube in a vein in your hand or arm for fluids or medicines. Not everyone needs one. It is usually recommended with an epidural, an oxytocin drip or antibiotics (for example for Group B strep), if you are dehydrated or vomiting, or if you have a higher chance of heavy bleeding. Sometimes a small cannula is placed and capped just in case. IV poles have wheels, so you can still walk, sway and go to the toilet.

When the waters are broken artificially

If your waters have not broken, your midwife or doctor may offer to break them (an amniotomy). During a vaginal exam, they make a small hole in the membranes with a thin plastic hook. It feels like a normal exam followed by a warm gush.

It may be suggested for a slow labour, as part of an induction, to check the colour of the fluid, or to place a scalp electrode. In a normal labour it does not shorten labour much on its own, and contractions often feel stronger afterwards. Once the waters are broken there is no going back: the aim becomes for your baby to be born within a reasonable time, because the risk of infection rises slowly. You can ask why it is suggested and decide whether you agree.

Communicating with staff

You are at the centre of every decision. For any suggestion, it helps to ask about the benefits, the risks, the alternatives, and what happens if you wait for now, and to notice what your instincts say. Your support person can ask these questions for you, and it is fine to ask for a few minutes alone to talk it over.

Say what is helping and what is not. If you want more information, less talking during contractions, or an explanation of the monitor, ask. If something must happen quickly, your team should still explain it briefly, and talk it through properly afterwards.

In short

The cervix softens, thins and opens to about 10 cm; with a first baby it usually thins before it opens.

Active labour is counted from about 5 or 6 cm and often lasts around 8 hours for a first baby and around 5 for later babies, with wide variation. Vaginal exams and every other procedure need your consent, and you can decline or ask for fewer.

In a healthy labour, intermittent listening to your baby's heart is recommended; continuous monitoring is used when there is a reason. Eat lightly, drink to thirst, pee every hour or two, keep moving, and shape the room so you feel safe.

Ask about benefits, risks and alternatives, and take a few minutes to decide when you can.