Transition, pushing and the birth · The First Year, Day by Day

This is the part of labour most people picture: the intense end of the first stage, the pushing, and the moment your baby arrives. Knowing what is normal, from the shaking and doubt of transition to the burning of crowning, makes it far less frightening.

Transition

Transition is the last part of the first stage, as the cervix opens from about 8 cm to fully dilated. It is often the most intense stretch of labour and usually one of the shortest, from a few minutes to an hour or two. Contractions may come every 2 or 3 minutes, last 60 to 90 seconds, and sometimes run together.

Common signs include:

Shaking or trembling, often in the legs, and feeling hot then cold. Nausea or vomiting, burping or hiccups.

Feeling overwhelmed, panicky or irritable. Many people say "I can't do this", "I want to go home", or ask for a caesarean.

Pressure in the bottom, like needing a bowel movement, and grunting at the peak of contractions.

These feelings are so typical that midwives often hear "I can't do this" as a sign the birth is close. Support people can help by staying calm and close, offering sips of water and a cool cloth, and saying simple things: "one at a time", "you are nearly there". If you want pain relief, say so; your team will talk about what is still possible (see "Pain relief with medicine").

The second stage

The second stage runs from full dilation to the birth of your baby. Care providers often describe two phases.

In the passive phase, the cervix is fully open but your baby's head is still moving down, and you may feel no urge to push. Contractions sometimes ease for a while, a pause some call "rest and be thankful". There is no need to push before you feel the urge; letting the uterus move your baby down saves your energy.

In the active phase, your baby's head is low and you feel a strong, often irresistible urge to bear down, or the head is visible. The urge comes from the head pressing on nerves in the pelvic floor and rectum. It usually builds at the peak of a contraction, so you may push two to four times in each one without deciding to. It can feel like the biggest bowel movement of your life. Passing some stool while pushing is common, means you are pushing in the right place, and staff quietly clean it away.

How long pushing takes
Without an epidural With an epidural
First baby Often 1 to 2 hours, usually under

These are not strict limits. What matters is that your baby keeps moving down and that you and your baby are well. If progress stalls, your team may check your baby's position, suggest a new position, consider an oxytocin drip, or talk about forceps or a vacuum (see "When labour needs help").

Positions for pushing

You can push in almost any position. Lying flat on your back, familiar from films, narrows the pelvis and works against gravity. Upright and side-lying positions are linked to a slightly shorter second stage, fewer assisted births and fewer episiotomies. Try what feels right, and change if things are not moving.

Semi-sitting in bed Familiar, easy for staff to help Weight on the tailbone, less room in

the pelvis

With an epidural you can still push on your side, semi-sitting, or kneeling with support if your legs allow. A peanut ball between the knees can help your baby descend while you rest.

Spontaneous and directed pushing

Spontaneous pushing means following your body: bearing down with the urge, for as long as feels right, and breathing in between. This is the usual recommendation without an epidural when all is going well.

Directed pushing means being coached to take a deep breath, hold it, and push hard for a count of about ten, several times per contraction. It may shorten the second stage a little but can tire you more and strain the pelvic floor. It is useful when you cannot feel the urge well, or when your baby needs to be born more quickly.

Pushing with an epidural

With a good epidural you may feel pressure but no strong urge. Many units suggest labouring down: waiting, often an hour or two after full dilation, while contractions bring your baby lower, then pushing once your baby is low or you feel more pressure. This usually means less time actively pushing and less exhaustion, though the second stage overall is longer. The epidural may be turned down a little if you feel nothing at all, but it is not usually stopped.

The baby's journey through the pelvis

Your baby does not slide straight out. The pelvis is a curved passage, widest side to side at the top and front to back at the bottom, and your baby twists and tucks to fit through. These steps are called the cardinal movements:

1. Settling in (engagement). The widest part of the head moves into the top of the pelvis, usually facing sideways. For first babies this often happens before labour.
2. Moving down (descent), throughout labour.
3. Tucking the chin (flexion), so the smallest part of the head leads.
4. Turning (internal rotation) to face your back, the best fit low in the pelvis. A baby facing your front ("back to back") often turns during labour, but labour may be longer and felt more in the back.
5. Lifting the chin (extension). Under your pubic bone, the head lifts and the face sweeps past the perineum: crowning and the birth of the head.
6. Turning back (restitution and external rotation). The head turns to one side to line up with the shoulders.
7. The body (expulsion). The top shoulder slips under the pubic bone, then the lower one, and the body follows.

Your baby's skull bones are not yet joined and can overlap slightly, which is why many newborns have a pointed head at first. It rounds out within days.

Crowning

As your baby comes down, the head bulges the perineum and shows at the opening with each push, then slips back between contractions. When the head stays visible between contractions, it is crowning.

Crowning usually brings an intense stretching, stinging or burning, sometimes called the "ring of fire". It is a signal to slow down, and for many people it fades quickly as the stretched skin goes numb. Touching your baby's head or watching in a mirror can bring a surge of energy.

Protecting the perineum

The perineum is the area between the vagina and the anus. Some tearing is common, especially with a first baby, and most tears are small and heal well (see "The third stage: the placenta and checking your body"). These help reduce the chance of a serious tear:

Warm compresses. A warm, damp cloth held on the perineum during pushing lowers the risk of severe tears and eases discomfort.

A slow, controlled birth of the head. You will usually be asked to stop pushing hard as the head crowns and to give short, gentle pushes or none. Breathing the baby out. Panting or blowing through a contraction, as if blowing out candles, lets the uterus ease the head out while the tissues stretch.

Hands on. Your care provider may support the perineum and gently guide the head.

Position. Side-lying and hands and knees put less strain on the perineum than squatting or lying on your back.

An episiotomy, a cut to widen the opening, is no longer routine. It may be suggested if your baby needs to be born quickly or for some assisted births, and needs your consent when there is time.

The cord around the neck

Once the head is born, your care provider often feels for the cord around your baby's neck. A loop is found in roughly one in four to one in three babies and is usually not a problem: the cord is long and slippery, and blood keeps flowing through it. The loop can be slipped over the head, or the body born through it and the cord unwound afterwards. Very rarely a tight cord is clamped and cut first.

The shoulders and body

After the head is born there is often a pause of up to a couple of minutes. Your baby's head turns to one side, and with the next contraction the shoulders are born one at a time and the body slides out quickly, often with a gush of fluid. Your baby will be wet and slippery, possibly bluish or purplish, with patches of a creamy coating called vernix.

Occasionally a shoulder catches behind the pubic bone (shoulder dystocia). It is uncommon, and teams practise for it. You will be asked to change position quickly, often pulling your knees to your chest or turning onto hands and knees, and someone may press just above your pubic bone. Most babies are born within a few minutes and do well.

Catching your own baby

If you would like to, many care providers will help you or your partner reach down and lift your baby onto your chest. Mention it in your birth preferences; your midwife or doctor will keep their hands close. Having no wish to do this is equally fine.

The first seconds

If you and your baby are well, your baby is placed straight onto your bare chest or belly, dried with a warm towel, and covered with a dry blanket and hat. Most babies breathe within seconds, then cry, cough or splutter, and turn pinker over the next few minutes. Hands and feet often stay bluish for a while. Some babies are quiet and alert rather than crying.

Your team watches your baby's breathing, colour, tone and heart rate, usually without taking them from you. The cord is usually left unclamped for at least a minute while your baby is well. If your baby needs help to breathe, the cord may be cut sooner and your baby taken to a warmer close by, usually for just a few minutes.

You may feel overwhelming love, relief, shock, numbness or plain exhaustion. All are normal. The placenta is covered in "The third stage: the placenta and checking your body", and the hours ahead in "The first hours after birth".

In short

Transition often brings shaking, nausea and "I can't do this"; it usually means birth is close.

The second stage has a passive phase for resting and an active phase for pushing; it often takes 1 to 3 hours for a first baby, less for later babies, longer with an epidural.

Upright and side-lying positions open the pelvis and are linked to fewer assisted births; change position if things are not moving.

Follow your own urge to push when you can; with an epidural, labouring down is common.

Warm compresses, a slow birth of the head and breathing your baby out help protect the perineum.

A cord around the neck is common and usually easily managed; most babies go straight onto your chest.