Labour

What is labour?

Labour is a sequence of events leading up to vaginal delivery of your baby (or babies). It begins with regular, painful muscle tightenings (contractions) in the womb (uterus). These gradually open (dilate) the neck of the womb (cervix) until it is fully open (fully dilated).

The contractions, together with your own pushing, then slowly push the baby down through the neck of your womb, past your hips (pelvis) and out through your vagina.

Labour is exciting and may also seem frightening. It usually takes place sometime around 40 completed weeks after your last period (this is the way pregnancy is measured, but it usually represents 38 actual weeks of pregnancy, as ovulation and fertilisation will have occurred about two weeks after your last period). Going into labour any time between 37 weeks and 42 weeks is considered normal.

Labour can start by itself (spontaneous labour), or it may be artificially triggered by your health carers (induced labour).

Labour is considered 'full-term' if it occurs between 37 and 42 weeks of pregnancy. Labour which occurs before 37 weeks of pregnancy is known as premature (or preterm) labour. See the separate leaflet called Premature Labour.

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Premature labour

In premature labour you start having regular contractions before 37 completed weeks of pregnancy. Most premature labour occurs between 34 and 37 weeks, but sometimes premature labour happens earlier. If you think you are in premature labour you should contact your midwife for advice, as soon as possible. Your healthcare team may need to assess you and your baby in hospital. There are treatments which can sometimes stop premature labour.

by Dr Hayley Willacy, FRCGP

How does labour start?

Surprisingly, we don't really know exactly what triggers normal labour. We know that changing levels of hormones - particularly of prostaglandins (in the amniotic fluid that surrounds your baby) and oxytocin (produced by you in your pituitary gland just beneath your brain) are involved in the beginning of the process but it's thought that proteins produced by your baby's maturing lungs may be an important part of the trigger to those changes.

Where can I give birth?

Giving birth in the UK is generally very safe for both you and your baby, wherever you choose to have your baby. Women can give birth in obstetric units, midwife-led units, or at home. The choice is one you can make after talking with your midwife and/or doctor. Their advice will depend on whether you and your baby are thought to be at low risk of problems in labour.

• If this is your first baby and you are considered low-risk then you should be offered the option of giving birth in a hospital or midwife-led unit.

• If this is your second or third baby and you are considered 'low-risk' then giving birth in a hospital, midwife-led unit or at home should be options for you.

Not all women can give birth where they plan or hope for. If your pregnancy is higher-risk (for example, if you are having twins, have pre-eclampsia or are in labour prematurely) then you will be strongly advised to give birth in an obstetric unit, for your own safety and for your baby's safety.

Women who are considered to be at low risk of problems, who decide to give birth in a midwife-led unit or at home, are less likely to have interventions (such as an assisted birth or an episiotomy) than those who plan birth in an obstetric unit.

Hospital birth

Many women prefer to have their baby in a hospital where there are skilled people and special equipment on hand. This may be particularly true if this is your first baby, or if you have had a difficult labour previously.

If you choose to have your baby in hospital, your local hospital is the obvious choice. If you have more than one maternity unit locally, you may want to visit it before you make a choice.

Midwife-led unit

Some women prefer to have their baby in a midwife-led unit. Midwife‑led units (also called birth centres) tend to be 'home‑like' and relaxed. Some are close to a hospital, ie stand-alone, and others are co-located with the obstetric unit within the hospital. Midwives are experts in normal pregnancy.

Home birth

Around 1 in 50 women choose to have their baby at home, in familiar surroundings. If you are assessed as being low-risk for complications and live close to your local hospital, this is a safe option. It means you don't have to interrupt your labour to go to hospital, you don't have to leave your other children, and you are more likely to be looked after by a midwife you already know. Home birth is not recommended if this is your first baby, as the risks to your baby are signficantly increased. It is also important to consider that in the UK almost half of women who choose home birth for their first baby are transferred to hospital. Your home will need to have a suitable room for you to deliver in, and you'll need a large plastic sheet to protect your carpet/floor. If you want to have a birthing pool at home, you will need to consider whether the floor is strong enough. If you choose to give birth at home, your midwife can transfer you to hospital if they are concerned for you or your baby.

What is a birth plan?

A birth plan is a written record of what you would like to happen during your labour and after you have given birth to your baby. Writing one can be a good way of helping you to think about your labour and delivery, and helps let your birth partner and your midwives know what you would like to happen. As well as thinking in advance about things like pain relief and breastfeeding, you can include details such as music you'd like to listen to, who should be your birth partner and supporter, and whether or not they would like to cut the umbilical cord.

If there is anything you feel really strongly about then a birth plan is even more important. However, you also do need to be flexible - labour is a time to have an open mind. If you expect things to be absolutely perfect then they almost certainly won't be, and you will feel disappointed or let down. Sometimes things change rapidly during labour, and things you wanted are not possible, particularly if complications develop for you or your baby.

Decisions about your care during labour will always take into account what you would prefer, whether or not you have a birth plan, but you should always be given clear advice about the pros and cons of the choices you are being offered.

You can change your mind about your wishes for labour and birth at any time.

How will I know I'm in labour?

Contractions usually signal the process of labour. These are painful muscular tightenings, which build up to a peak and then tail off. They can initially resemble Braxton-Hicks contractions (sometimes called practice contractions) in late pregnancy.

• Some women worry that they won't know the difference between Braxton-Hicks contractions and actual labour. Braxton-Hicks contractions can be uncomfortable enough to make you stop what you're doing, and take deep breaths, but they are not usually painful. They tend to occur at twenty-minute intervals, typically lasting 30 seconds or so. They tend to fade away about as quickly as they build up, whereas labour contractions build up slowly and are painful.

The contractions of early labour may come at irregular intervals at first, and this period of time can go on for some hours (particularly if this is your first time in labour). Eventually the pains will become regular. At first they may be 10-15 minutes apart but they will become closer and closer together. As they become closer together they may also become stronger, longer and more painful. During the contractions your womb (uterus) will feel hard to the touch.

Having a 'show'

Many women have a 'show' in the days or hours before labour starts. This is a thick plug of mucus, often with a bit of fresh blood in it, which comes out of the vagina. It has come from the neck of the womb (cervix). It shows your body is getting ready to have the baby.

What is normal labour like?

There are three stages of labour. The first stage of labour is divided into the latent period and established labour. The amount of time taken for each varies from woman to woman. Labour - particularly the first stage - also tends to be longer for women in their first pregnancy than for those who have already given birth.

The first stage of labour: the latent period

The latent period is the first part of labour, when your womb (uterus) begins to contract. Contractions are often (but not always) painful. They may at first be irregular as your womb begins to co-ordinate the action of its muscle fibres. The latent stage of labour varies hugely between women. It can last hours or days, can stop and start, and there may be periods when contractions seem to be getting longer and more regular before they seem to fade away or become irregular again. This can be slow and frustrating, particularly when this is your first baby. You may feel upset that you are not making progress. It's best to stay at home during the latent period and rest as much as possible - view any breaks in latent labour as an opportunity for you to take a rest, as things will start again soon. The womb can take its time to make effective contractions and really 'get into gear', particularly when it has not done this before.

Your waters may break during the latent period and you may have a show, which may be streaked with blood (although if you see more blood than this you should contact your midwife or labour ward. You should also contact them for advice if your waters break). You may feel a sense of pressure in your pelvis and may find you want to pass urine or open your bowels several times.

As time goes on, the contractions become more effective and act upon the neck of the womb (cervix) itself, causing it to soften, thin (efface), become stretchy and then start to open (dilate). This works because the womb is made of unusual muscle fibres which, at the end of each contraction, are a tiny bit shorter than before it began.

If you go to hospital before labour is established (during the latent period), you may be sent home until things are more advanced. This can be frustrating, as the latent period is tiring and the contractions are usually painful. When experiencing the latent phase things that may help include:

• A warm bath to help with the pain.

• Distraction and relaxation techniques, listening to music or watching TV.

• A transcutaneous electrical nerve stimulation (TENS) machine.

• Focusing on your breathing control during contractions. As you become aware of a contraction, breathe out slowly as if you are sighing. Then as the sensation builds, continue to blow away the pain by making your out-breaths as long as possible. As you breathe out, relax your body as much as possible. You can try to do this by focusing your attention on relaxing the muscles in the parts of your body that don't hurt.

• Eat regular, small snacks and drink plenty of water, in order to maintain your energy levels and hydration for labour. High carbohydrate food is best, as the energy in it is easily accessible by your body but unlike pure sugars it also lasts a little while.

• If it is night time, try to rest. If it is daytime, try to remain upright and mobile, as gravity will help labour become established.

• From time to time note the interval between contractions (the time from the start of one contraction to the start of the next) and how long they are lasting. When your contractions are regular, lasting 60 seconds or more and coming every 4-5 minutes, it is likely that you are moving into established labour.

The first stage of labour: established labour

This is usually defined as beginning when the cervix is 4 cm dilated. If you are having regular, painful tightenings (or you think your waters have broken), you should contact your maternity unit straightaway. You are likely to be asked to come in, to check whether you are not in established labour. When you arrive your midwife will want to examine you vaginally, to assess the progress of your labour, particularly whether your baby has moved down into your pelvis, and whether your cervix is dilating. You will also be asked about your general health, whether you have had any bleeding and whether you think your waters have broken. Your midwife should talk with you about how you are feeling, and ask whether you need pain relief. They will carry out a number of checks, including:

• Measuring your baby's heartbeat at intervals or, sometimes, continuously.

• Checking how often you are having contractions, every 30 minutes.

• Measuring your pulse every hour.

• Measuring your temperature and blood pressure every four hours.

• Checking how often you empty your bladder.

• Offering vaginal examinations every four hours, or more often if there are any concerns or if you want this.

Once labour is established your contractions will be more regular and more effective, typically becoming more intense at their peak. The muscle fibres of your womb are special muscle fibres. Each time they contract and then relax in labour they become slightly shorter, and this has the effect of pulling the cervix up and open. At the same time your baby is being squeezed downwards so that they sit lower in your pelvis, pushing against the cervix. Gravity (if you are standing up or walking around) and the pressure of your baby's head on the cervix make this process more efficient.

In the established first stage of labour, you go from 4 cm of cervical dilatation to being fully dilated, or 10 cm dilated, when your cervix can no longer be felt around the edge of your baby's head. If your labour is going well and your baby does not appear to be unduly stressed, you shouldn't need any medical procedures or equipment, such as having your waters broken or being connected to an electronic monitor to check your baby's heartbeat. Most women are able to be up and about for most of the first stage.

• It is still important to keep your energy levels up. Sports drinks (isotonic drinks) are good for labour. Eat light energy foods such as fruit and toast if you feel hungry.

• Drink plenty of water to keep yourself hydrated.

• You will be encouraged to try to pass urine regularly. If you are unable to pass urine because you have an epidural, you may be asked if you would be happy to have a catheter inserted to empty your bladder, as a full bladder is easily bruised during the second stage of labour.

In your first labour the period of established labour may last 8-18 hours (although 12 hours is typical). In women who have already had a baby through vaginal labour it tends to last 5-12 hours (eight hours is typical). As the contractions intensify you may be able to use natural techniques to manage them, but may also want to think about other options for pain relief.

The end of the first stage of labour: transition

The first stage ends when the cervix is 10 cm (fully) dilated. You may get the urge to push towards the end of this stage but should avoid it until you know you are fully dilated, as it is important that no 'lip' of cervix can still be felt at the edge, as this could be bruised or damaged if you push too soon. Your midwife may need to examine you internally to check that the rim of your cervix can no longer be felt. The end of the first stage of labour is called the transitional phase. You may suddenly feel you've lost control of things. This phase does not last for very long and is usually a sign that the second stage is about to begin.

The second stage of labour

The second stage begins when the cervix is fully dilated, and ends with the birth of the baby. You may not have an urge to push with your contractions straightaway - this is called the passive second stage. The active second stage starts when you have an urge to push with most contractions, and ends when your baby is born.

Your baby's birth is expected to take place within three hours of the start of active pushing in most women having their first baby, and within two hours for most women who have had a vaginal delivery before. During the second stage your baby's head will start moving down through your vagina. Your midwife will help and encourage you and will monitor you and your baby closely. You should be guided by your midwife and by your own urge to push.

The urge to push feels rather like the urge to do a poo, and pushing uses the same muscles. Your midwife will talk you through how to push most effectively. You can start to push when you feel you need to during contractions. Take a deep breath when the contractions start, and push downwards, into your bottom. Take another breath when you need to. Try to give three good pushes before the contraction ends. Some women find it hard not to scream or speak when trying to push, but it's better to try to keep your mouth closed, as your push will be stronger that way. After each contraction, rest and get your strength up for the next one. Sometimes during a contraction, you may open your bowels slightly without realising it. This is common and nothing to be embarrassed about. Your midwife will clean you straightaway. However, many women need to open their bowels frequently during the first stage of labour, so that there is nothing left to come out of the bowel at this point.

Your midwife will usually encourage you not to lie on your back but instead to find another position that is comfortable. If pushing doesn't seem to be working well your midwife may advise you to change position, and to empty your bladder. You will need to find a position that works for you. You may want to lie, stand, kneel, squat or go on to all fours to deliver your baby. The active second stage of labour is hard work. You will need support from your birthing partner and your midwife.

The baby's head gradually moves down with your contractions and pushing, until it can be seen at the entrance to your vagina. When they arejust about to be born, so that your vagina starts to stretch open (crowning), the midwife will ask you to stop pushing, and instead to pant or puff quick through your next contraction in short breaths, blowing out through your mouth. It's important not to push at this point, so that your baby's head can be eased out slowly and gently, giving the skin and muscles around your vagina time to stretch without tearing.

The skin of the perineum usually stretches well, but it may tear. Sometimes, to avoid a large tear or to speed up delivery, your midwife (or doctor) will inject local anaesthetic and make a small cut called an episiotomy. Afterwards, the cut or tear is stitched up again and it usually heals quickly.

Once your baby's head is delivered, the hardest part of the pushing stage has passed. It usually takes only one more push for the rest of your baby to be born. Your baby will usually be lifted straight on to you - this skin-to-skin contact at birth can really help you and your baby to bond. Your baby will be covered with a towel or blanket for warmth. The cord should not be clamped or cut straightaway. If you would like to breastfeed your baby, you can do so as soon as you wish, and you will be encouraged to start within one hour of the birth (30 minutes if you are on insulin for diabetes or gestational diabetes). You shouldn't be separated from your baby in these first minutes, unless this is essential to provide urgent care.

Your baby will be checked to make sure their heart and lungs are doing all the right things and that they're a good colour and look healthy. Your midwife will complete an Apgar score at one minute and another five minutes after they are born. The test is so quick you may not even notice it being done. Your midwife will check your baby for a number of factors including:

• Skin colour.

• Heart rate.

• Reflex response.

• Muscle tone.

• Breathing.

Most babies will show no signs that cause concern, but if the midwife notices any issues he/she can call for immediate treatment.

The third stage of labour

This lasts from the birth of the baby until the afterbirth (placenta) is delivered. You can usually hold your baby during this stage if you want to.

The placenta remained attached to the wall of your womb during labour, but as your baby comes out of you and your womb contracts down, your placenta will shear off and come away from it completely. It is a soft, flexible disc of tissue, with the cord still attached, which will then need to be expelled from your womb by your contractions. When you were pregnant, a midwife should have explained to you about the two options for the third stage, and about the pros and cons of each. They are called active management and physiological management.

• In active management, you are given an injection of a medication called syntometrine, usually as you are giving birth. The cord is clamped and cut 1-5 minutes after your baby is born. The syntometrine makes the womb contract firmly and push the placenta out, and the midwife also pulls gently to help this process. Active management speeds up the delivery of the placenta, and lowers your risk of heavy bleeding after delivery (called postpartum haemorrhage).

• In physiological management, the third stage of labour is allowed to happen naturally, as long as it doesn't take more than an hour. No syntometrine injection is given, and the cord is not clamped until it has stopped pulsating. You push the placenta out yourself, with contractions. If this process takes more than an hour, or you have any heavy bleeding, you will be advised to change to active management.

Allowing your baby to breastfeed at this stage also makes the womb contract and reduces the risk of bleeding.

Your midwife will carefully examine the placenta to make sure that it has come out whole, and will check your blood pressure, pulse and temperature, make sure that you can empty your bladder, and check you're feeling OK. Unless your baby is unwell, you should have an hour with him or her before your midwife borrows him or her for weighing and baby checks.

When will my waters break?

Your 'waters' are the amniotic fluid around your baby which protects your baby and keeps them warm. This fluid is contained in a membrane which usually pops at some point during labour, releasing a warm gush of fluid. You may feel a popping sensation and then a gush, although you may not notice this if it happens during labour.

The membranes break before labour has started in about 1 in 12 labours. You will usually feel a pop and then a gush of clear fluid, followed by a constant trickle which means you will need to wear a pad.

When your waters break but you don't go into labour

If you are not yet in labour but you think your waters might have broken, you may be offered an internal examination with a device called a speculum. If it's obvious that your waters have broken then you won't need this examination.

Once your waters have gone there is no protective layer between your baby and the outside world. About 3 out of 4 women go into labour within 24 hours of their waters breaking at full term (more than 37 weeks of pregnancy), and 9 out of 10 within 48 hours. If you do not, your hospital team will usually talk to you about starting (inducing) your labour. This is because the risk of infection for you and your baby starts to increase after a prolonged period without the protection of the amniotic fluid, so it is better for your baby to be persuaded to come out of your womb (uterus).

If you choose not to be induced at this point, you will be advised to check your temperature regularly - usually every four hours while you are awake. You will be advised to contact your midwife it:

• You develop a high temperature.

• You notice any change in the colour or smell of your vaginal discharge.

• Your baby is moving less.

Your baby's heartbeat should be checked at least every 24 hours by your midwife during this time. Having a shower or a bath won't increase the risk of infection, but having sex might.

What if my labour needs to be induced?

In induction of labour, your body is triggered into labour by your doctor or midwife. It's used when it's thought that your baby would be safer being delivered than remaining in the womb (uterus). Common reasons for induction of labour include:

• Your waters broke but you did not go into labour by yourself.

• Your baby's growth has slowed.

• You have pre-eclampsia.

• You are more than 41 weeks pregnant.

• You have diabetes and are nearly at full term.

Induction of labour should be discussed with you in detail before it is done, and it is only done if you give your consent. Methods include:

• Membrane sweeping, where your midwife does a vaginal examination and puts a finger into your cervix, sweeping it round in a circular motion to try to separate the membranes from the cervix. It has the best chance of working if your cervix is already soft and ready for labour.

• Prostaglandin gel or pessary - this aims to soften your cervix and prepare it for labour. The medication is put high into the vagina.

• Oxytocin with/or without artificial rupture of membranes - this stimulates your womb directly to start contracting, if your cervix is ready. Oxytocin is sometimes called syntocinon, which is the name for synthetically produced oxytocin (as opposed to that you produce yourself).

Artificial rupture of the membranes (amniotomy)

This is a procedure in which your midwife breaks your waters for you. This can be done for several reasons, including:

• To start off (induce) your labour. There are lots of prostaglandins in amniotic fluid - these are substances that tend to stimulate womb (uterus) contraction as they leak out.

• To encourage your first stage of labour to progress.

• To allow the midwife to place a fetal scalp electrode on your baby's head for monitoring of their heart rate.

• To prepare you for an assisted delivery if your waters haven't yet broken.

• If the waters haven't broken and your baby is about to be born, they are usually broken to prevent your baby from breathing in amniotic fluid with their first proper breath.

The membranes may be ruptured using a special tool - either an amnihook (which looks a little like a crochet hook) or an amnicot (a tiny hook which goes ont the end of the fingertip), or sometimes just with the midwife's finger.

What if my labour is too slow?

When the labour is taking longer than expected, it is called delay in labour. It can happen at any stage of labour. You should be offered support and pain relief, and be advised to move around or change position. You may need to be transferred to an obstetric unit if you are at home or in a midwife-led unit, so that extra care is on hand if needed. Sometimes it is recommended that the labour or birth be speeded up if there is a chance that the delay may cause problems for you or your baby.

If your labour is slow, your doctor and midwife will want to think about the possible causes. It may be that your womb (uterus) is not contracting as efficiently as it should, or that your muscles are becoming tired. It is also possible that your baby is too big or in a slightly awkward position, and your womb is finding it difficult to move your baby down through your pelvis.

Delay in the first stage

If the first stage of labour is slow, your midwife or doctor may suggest breaking your waters if they haven't broken already. This may make your contractions stronger and more painful, and may speed things up.

You may also be offered a drip with oxytocin (a medication that makes your contractions stronger). This will also tend to speed things up but also to make contractions more painful. You should also be offered an epidural, and electronic monitoring will be recommended.

If the first stage is extremely slow, or your baby is in a difficult position, or seems not to be moving down through your pelvis, your midwife and doctor will need to consider whether labour is slow because the womb is tired, or because it is proving too difficult for the baby to be delivered vaginally, in which case you might be advised to consider an operative delivery like a caesarean section (C-section).

Delay in the second stage

If your contractions are weak at the start of the second stage and this is your first labour, you may be offered an oxytocin drip to make your contractions stronger. You should be offered an epidural at the same time.

If the second stage seems to be taking too long then the midwife may suggest breaking your waters (if they have not already broken). You may be offered an oxytocin drip to speed up your labour and, if so, you will also be offered an epidural.

If your second stage is very prolonged, if your baby doesn't seem to be moving down the birth canal, or if your baby is becoming too tired then your midwife and doctor may advise an assisted delivery using forceps or ventouse, or an operative delivery (caesarean section).

See the separate leaflets called Assisted Delivery and Caesarean Section.

When and how is baby monitoring done in labour?

Electronic monitoring involves being attached to a monitor that continuously monitors your baby's heartbeat and your contractions. If labour is straightforward this does not generally need to be continuous, but continuous monitoring is more likely to be done if:

• You have an epidural.

• You have a drip to speed up labour.

• Your baby has passed thick meconium (suggesting they may be tired or stressed).

• You have high blood pressure, a high pulse rate or develop a temperature.

• You have any unusual bleeding.

• You are progressing very slowly.

• Your midwife has concerns, when checking your baby's heartbeat, that your baby may be tired.

• You're expecting twins.

• Your baby is thought to be unusually small.

• You have diabetes.

• Your BMI is very high.

• You have previously had a caesarean section.

Electronic monitoring is only done on an obstetric unit, so if you are not there you will need to be transferred. Most monitors allow you to move around.

Your baby can be monitored in several ways which either check their heartbeat or check the balance of chemicals in their blood.

Pinard stethoscope and Doppler ultrasound

Your midwife will listen to your baby's heartbeat regularly after a contraction, but not all the time. How fast, how regular and whether there is any slowing of the pulse, will tell the midwife a lot about how the baby is doing. They will normally use a small machine called a Doppler ultrasound (Sonicaid^®) to hear the heartbeat. This has a probe which is placed on your tummy, a bit like an ultrasound scan. You will be able to hear the heartbeat too. It sounds very fast but it is normal for a baby's heartbeat to be 120-160 beats per minute. If they use a type of stethoscope called a Pinard, only the midwife will be able to hear your baby's heartbeat.

Electronic monitoring

An electronic sensor is placed on top of your tummy to measure contractions and is held in place with a wide elastic belt. Another, just the same, is placed over your baby's heartbeat to count the beats. They are connected to a machine called a cardiotocogram (CTG); this process is called cardiotocography.

Fetal scalp monitoring

If your waters have broken and a better, more accurate monitoring of the baby's heartbeat is needed, the probe can be attached to the baby's head. This is called a fetal scalp electrode (FSE). It gives a better recording because it is directly attached to the baby and doesn't have to go through your tummy wall. The FSE is not thought to hurt the baby because it just clips on to the scalp.

Fetal blood sampling

This test measures the level of oxygen in the baby's blood. It may be suggested if your midwife or doctor thinks your baby is becoming stressed. They can only do this if your waters have gone and the neck of your womb (cervix) has opened up (dilated) a little.

It involves having a vaginal examination using a device like a speculum. A tiny scratch is made on your baby's scalp to take a small amount of blood for testing. The process of trying to taking a blood sample sometimes improves the baby's heartbeat. If your baby is in the breech (bottom -first) position, the blood sample can be taken from your baby's bottom.

What is fetal distress and what happens if my baby becomes distressed?

Fetal distress is the medical term for when your baby is getting stressed and tired by labour. Labour is tiring for both you and your baby. Each time your womb (uterus) contracts and squeezes your baby, it temporarily closes off their blood supply. Your baby is designed to withstand this, and have enough recovery time between contractions. However, towards the end of labour, when your contractions are close together, your baby gets less and less recovery time. In this case labour for your baby may be the equivalent of running up a hill, and they may get tired and start to recover less well between contractions. Your baby's oxygen levels may then fall.

Signs that can indicate fetal distress include:

• Changes in the pattern of your baby's heart rate when monitored, including abnormally high or low rates, and slowing of the heart rate during contractions that doesn't recover well afterwards.

• Lower levels of oxygen when your baby has a scalp blood test.

• Your baby passing their 'first poo' (meconium) whilst still in the womb - particularly if a lot of meconium is passed.

Fetal distress is more likely if your baby is small or premature, or if you have pre-eclampsia. If your baby is showing signs of fetal distress your midwife and doctor will discuss this with you, explaining whether they feel delivery needs to be hurried along in any way, and whether your baby needs any additional tests or monitoring.

Fetal distress may be a gradual or a sudden event. Most fetal distress happens gradually, with your baby showing increasing signs of tiredness. There is plenty of time to decide what is the best thing for you and your baby, and the options will depend on how close your baby is to being born, and will be discussed with you as things change.

Sudden severe fetal distress is rare but can happen quickly. There may not be much time to discuss things. It tends to happen because something has interrupted the baby's blood supply. This can include the umbilical cord becoming so tangled around your baby that it is squashed and the blood can't flow, or the umbilical cord dropping out through the cervix ahead of your baby so that it gets completely trapped between your baby and the birth canal (cord prolapse). Both these events are very unusual, as the umbilical cord is long and slippery and not easily squashed through being tangled. It's unusual for the cord to come down ahead of the baby, as the baby's head is usually tucked down into your pelvis long before labour begins, so there itsn't space for the cord to slip past.

If your baby becomes very distressed your midwife and doctors will talk to you about the options. The choices offered to you will depend on how stressed your baby seems to be, on how you feel and on how far through your labour you are.

Possible options may include

• Continuing with labour, with more intensive monitoring

• Assisted delivery with ventouse or forceps.

• Caesarean section to deliver the baby immediately.

What if labour starts too soon or doesn't happen on time?

Labour is said to be 'too soon' (premature labour) if it comes before 37 completed weeks of pregnancy. Most babies can breathe for themselves after 32 weeks of pregnancy. The main challenges for babies born between 32 and 38 weeks are keeping warm, feeding and not picking up an infection. See the separate leaflet called Premature Labour.

Labour normally happens before the 42nd week of pregnancy, and doctors and midwives will ask you to consider induction of labour if you go beyond 41 weeks. If your labour doesn't start, you will be examined to see how likely it is that labour will start soon. You will be offered induction of labour; that is, a doctor or midwife will start your labour artificially. This is either done with a hormone (prostaglandin) gel that is placed into your vagina, or by breaking your waters and giving a medication into one of your veins.

The gel contains a hormone that makes the neck of the womb (cervix) soften and start to open up (dilate). Your contractions will start and become stronger and stronger, as normal. The pessary is given in the hospital ward and you are taken to the labour ward, when your labour has started.

Your waters are usually broken on the labour ward. A midwife or doctor uses something that looks like a crochet hook to make a hole in the bag that holds the water. This does not hurt the baby or you. Usually your contractions start after that but if they don't a drip will be put in your arm. This allows a different hormone to be given, which will start your contractions. The midwife can control how much hormone you receive and therefore how strong your contractions are. The contractions will need to be strong and close together to deliver the baby. Contractions may be more painful if medication is used to start off (induce) your labour or to speed it up.

Questions you may have about labour

Who will look after me in labour?

Most women are cared for by midwives. They are highly trained and expert in normal delivery. If they are worried by any aspect of your pregnancy or labour they will ask an obstetrician to see you. Obstetricians are doctors who specialise in pregnancy and childbirth. They perform procedures and deliveries when needed.

Labour wards will allow your partner or friend (birthing partner) and possibly one other person to stay with you during labour. These people are important sources of support for you. They can talk to you, hold your hand and rub your back, if you want it. They can also help you to make any decisions you might need to during labour.

Can I eat and drink in labour?

Most women who are having a normal labour are encouraged to eat and drink. This helps keep your energy levels up, and keeps you hydrated. It's best to be guided by what you feel like eating, and eating little and often, remembering that you will digest food more slowly in labour since your body is concentrating on supplying blood to your womb (uterus) rather than your stomach. Carbohydrate snacks such as biscuits, crackers, breads, cereal and sandwiches probably give you the best balance of easily digestible, lasting energy.

Water and isotonic drinks are good to drink. Once you're in established labour you may not feel like eating, but you should try to stay hydrated by drinking or sipping liquids.

If your doctor or midwife thinks that your chances of needing a caesarean section are raised, you may be advised to stop eating, so that if you do need surgery you don't have a full stomach. It is not essential to have an empty stomach for surgery - the anaesthetist will take particular care that you're not sick in surgery - but if you have a very full stomach you are probably more likely to feel sick or be sick (vomit) afterwards.

Can I walk around in labour?

Staying mobile in labour is a good thing, and most women are encouraged to do it as much as possible. Being upright probably makes each of your contractions a tiny bit more effective, as the weight of your baby is weighing downwards against the cervix helping to persuade it to stretch open. Walking probably helps to stimulate contractions.

If you have an epidural it is possible that you may be able to walk around - it depends on the type of epidural you have been given and on how you respond to it. Most women don't walk around with their epidural. An ambulatory, or walking, epidural is a type of epidural which aims to allow you to walk by combining an epidural with a painkiller, but these are not always available. A walking epidural may allow you to walk around, although you will be attached to a drip stand, and the medications will reduce your strength and balance (and reaction times) and might make you feel a little dizzy, so someone should always be with you.

Can I use a birthing pool?

If you would like to use a birthing pool in hospital or in a midwife-led unit then you will need to speak to your midwife during pregnancy to find out whether any local birth centres or hospitals have a pool and suitably trained and experienced midwives. If you are planning a home birth you will need to hire a pool well in advance, and make sure that you know that your floor can support its weight, and that you know how long it will take to fill and empty. Birthing pools need to be emptied, disinfected and refilled every 24 hours.

You will need to consider whether you are hoping to use the pool for pain relief during labour, or whether you want to plan a water birth. In a hospital or birth centre you may only be able to use the pool for active labour, when your cervix is past 4-5 cm dilated, and the pool may only be available if nobody else has got there first. Some hospitals allow your partner to get into the pool with you.

You are likely to be advised against using a birthing pool if your labour is not considered low-risk. A pool wouldn't generally be used if:

• You are unwell or have a temperature.

• You are in premature labour.

• Your waters have been broken for more than 24 hours.

• You are on a drip to speed up your labour.

• You are having twins or more (although some units might allow you to use the pool in early labour).

• You have had genital herpes.

• Your baby is distressed or has passed 'first poo' (meconium).

• Your baby needs continuous fetal monitoring.

• You have been given an opiate medicine such as pethidine and are drowsy.

What is giving birth in water like?

The warm water and relaxed environment of a birthing pool help to ease labour pains and may make you more relaxed during labour. It's also easier to change position as you are giving birth.

You can use gas and air (Entonox®) during a water birth - if you are at home your midwife can bring this to you in a cylinder. TENS machines, pethidine (and other opiates) and epidurals are not possible in a birthing pool.

If you are planning to deliver into the pool then your midwife will get into the pool with you. Your baby will be born into the water, and won't take a breath until their head is above the water. This is because your baby's natural diving reflex prevents them from trying to take their first breath whilst still underwater. Your midwife will know how to avoid doing anything which might override this reflex. In particular he or she will not bring your baby's head to the surface before the rest of their body is born (as this might trigger an early breath).

Your blood pressure and temperature and your baby's heart rate will be monitored (with a waterproof tummy sensor) whilst you are in the pool. If your baby is distressed then you should not deliver under water, as if your baby's oxygen supply via the placenta is running short this may increase the risk that they try to breathe underwater. Your blood pressure, pulse and temperature will also be monitored. Your midwives will get you out of the pool quickly if there is any reason to do so, particularly if you feel unwell or your baby is distressed. Once your baby is born you will be able to hold and feed him or her straightaway.

You may be asked to get out of the pool for the delivery of the placenta.

When can I feed my baby?

You will be encouraged to feed your baby as soon as possible after delivery. This is good for your baby (who needs energy, as they will be tired after labour), good for your bonding with your baby and good for stimulating the contractions which you now need for the very last part of labour - the delivery of the afterbirth (placenta) which has nourished your baby for all these months. Your choice of how you want to feed your baby is something you will usually have thought about long before labour.

What if the placenta doesn't come out?

Sometimes, part or all of the afterbirth (placenta) stays inside the womb (uterus). If this happens, you will be put on a drip and you may need a vaginal examination to check whether the placenta will have to be removed manually. This examination can be painful, so you will be advised to have pain relief. You may be advised to have an epidural or spinal anaesthetic when the placenta is removed.

What if I need stitches?

You may need stitches if you had a cut after a local anaesthetic (an episiotomy) or a ventouse/forceps delivery. Sometimes the skin of the area between your vagina and anus (the perineum) can split or tear during delivery of the baby's head, and these types of tears also sometimes need stitching.

You will be given local anaesthetic if you need it - for example, if you don't have an epidural - before the stitches are put in, and this will be done as soon as possible after birth, in order to get the best healing and reduce the chance of infection or bleeding. Usually, you will be asked to have your legs up in stirrups to help the doctor or midwife place the stitches. Afterwards, you may be offered a small anal suppository - a tablet in the back passage - to help reduce inflammation and pain. You should be given health information about painkillers, diet, hygiene and pelvic floor exercises.

If you have had your baby in hospital, after delivery you will be taken from the labour ward to the maternity ward. You will be able to feed your baby, if you haven't already. One of the nursing staff will wash your baby. At some point a doctor who specialises in children may come to examine your baby. This is a top-to-toe examination designed to pick up anything that isn't quite right. If problems are found you will be asked to bring your baby back to a specialist clinic.

How long you stay in hospital will depend on what type of delivery you had and how well you are. If it is your first delivery you may need to stay a little longer, even if it was a normal vaginal delivery. Different labour wards have different policies about discharge. You can ask them about their discharge policy when you visit.

What if I have bleeding after my baby is delivered?

Unusual bleeding after your baby is delivered is called postpartum haemorrhage. It can be an emergency, depending on how much you are bleeding, and your midwife and doctors may need to take swift action,even before they can explain things properly. It usually happens because your womb (uterus) is more relaxed than it should be after the afterbirth (placenta) has been delivered, allowing the large blood vessels inside to bleed. Sometimes this is because the placenta has not completely come out. Treatment may include:

• Injections (one or more) of oxytocin to 'remind' your womb to contract down tightly.

• Fluids, oxygen and (more rarely) blood transfusions for you.

• Moving to 'active management' of your third stage if you had previously chosen 'physiological management' (see under the third stage of labour, above).

• If this fails, transfer to theatre for examination under anaesthetic.

Labour in differing circumstances - breech, twins, HIV, herpes

Can I have a vaginal labour if my baby is in the breech position?

If your baby is in the breech position in late pregnancy you may be offered external cephalic version (an attempt to turn your baby by manipulating your bump) in late pregnancy. Not all women can have this, and your obstetric team may be cautious about it if you have previously had a caesarean section.

If the baby stays head-down after this, a vaginal delivery is usually considered the best option. If the baby stays in breech position, you will be offered caesarean section, as this is felt to be the safest option for you and your baby. Babies can be delivered in the breech position, and in many countries of the world they often are. However, babies sometimes adopt the breech position for a reason, and this can be because the shape of your pelvis does not encourage a head-down position. There is a chance that this means that your pelvis is narrow for your baby's safe and easy exit. If this is the case and a breech delivery is attempted, there is concern that the baby's shoulders may get stuck, leading to a very difficult delivery.

Can I have a vaginal labour with twins?

Some women with twins have vaginal labours, and others are advised to have a caesarean section. The decision is one you need to make with your consultant. Vaginal delivery is more likely to be offered if your twins do not share an afterbirth (placenta), and if the first twin is presenting head-down. Your obstetrician will discuss this with you in much more detail.

Can I have a vaginal labour if I have HIV?

You can usually have a vaginal birth provided that your viral count is low. Providing this is so and you are on antiretroviral therapy, a vaginal delivery does not increase your baby's chances of acquiring HIV above a caesarean section. An exception would be if you are also hepatitis C-positive.

Can I have a vaginal delivery if I have genital herpes?

You can normally have a vaginal delivery unless your first ever attack of genital herpes occurs at or later than 34 weeks of pregnancy. In this case you would not have had time to pass immunity to your baby, and your baby could catch a serious infection at the time of birth. In this case you would be recommended to have a caesarean section.

What is cord prolapse?

A cord prolapse occurs when the umbilical cord comes down the birth canal ahead of your baby. It's a rare event, as in late pregnancy your baby's head is usually right down in your pelvis and the cord can't come past. It is more likely to occur if your baby is in the breech position, because there may be space for the cord to come past the baby's bottom, or if your waters break when your baby is small and premature, so that he or she hasn't dropped down into your pelvis yet when your waters break.

Cord prolapse is an emergency, as the cord gets squashed by the descending baby. You may be asked to get on to your hands and knees, leaning forwards, whilst the midwife pushes your baby back up to take their weight off the cord. You may need an urgent caesarean section.

What if the cord is knotted or tangled around my baby or around my baby's neck?

Many mothers worry about this. Babies are often tangled in their umbilical cords. In 1 out of every 3 to 4 deliveries, as your baby comes down your birth canal, the long slippery umbilical cord is looped around your baby's neck. When your baby's head is born your midwife will see the cord there, and will either slip the loop over your baby's head, or loosen it so your baby's shoulders can pass through. This is generally easy to do.

The cord is long and strong, and covered in a substance called Wharton's jelly which makes it highly resistant to being squashed. Even when your baby's somersaults so much in the womb (uterus) that he or she makes a true knot in the cord (which happens in 1 in 100 pregnancies), it will not get squashed. Sometimes quite complicated knots are seen. The cord also will not 'pull tight' as your baby moves down the birth canal. This is because as your baby moves downwards, the top of the womb and the afterbirth (placenta) move downwards with him or her. The cord gets far less pulling in labour than earlier in pregnancy when your baby is somersaulting around.

Occasionally the cord can be too tightly wound around your baby's neck for your midwife to easily unloop it or to for your baby to be born through the loop (the other end of the cord is still attached to the placenta inside your womb). In this case your midwife may clamp and cut the cord before your baby's shoulders are born. Your midwife will explain this to you if it is needed. Remember that, however many times the cord is around your baby's neck, your baby doesn't breathe through their windpipe until after birth - their oxygen supply comes through the cord not the windpipe and lungs, so your baby will not be strangled by the cord.

Lots of studies have compared the births of babies with the cord around their neck and babies without, and have found that babies with the cord around their necks are no more likely to have problems around delivery than babies who haven't. However, if your baby does experience fetal distress late in labour and then is born with the cord around their neck, people will often suggest that the cord was probably the cause. The truth is, this can happen whether or not the cord is around your baby's neck. Baby's get tired and stressed when being squeezed down the birth canal, and the cord was most probably not the cause of this.

What are afterpains?

Afterpains are pains from your womb (uterus) as it contracts back down towards its normal size after birth. They are at their most intense straight after delivery, but will continue for several days and will often be triggered by breastfeeding.

Afterpains can feel exactly like contractions, or they may feel more like bad period pains, or they may be somewhere in between. They tend to get worse the more babies you have had. This is thought to be because first-time mothers have better muscle tone in the womb, so it is better at staying contracted after each pain, rather than relaxing and then doing it again.

When you have just delivered you might be able to use gas and air for the first few afterpains, and if you have an epidural this will prevent you from feeling them initially. After this, it's often best just to breathe through your afterpains. Paracetamol or ibuprofen may help slightly, and a hot water bottle or warm bath may also be helpful. The pains will usually start to tail off on the third day.

What if my birth didn't go according to plan?

Childbirth is unpredictable and it doesn't always go according to plan. No matter how much you hope to stay in control of events in childbirth and your response to them, life, labour and your body will prevail. It's very hard to stay in control when it's your body, not your brain, deciding what happens next, and when you are advised to choose options like assisted delivery that you hoped to avoid and did not plan for. None of us likes to lose control of a situation we are in, and you may have found this frightening, either at the time or afterwards. Most women also spend a lot of time imagining and planning for the labour they hope to have, so you may also feel cheated, disappointed, sad or angry. It can help to:

• Talk to your partner and your midwife about how you feel. If decisions were taken in your labour that you don't clearly understand, ask for them to be explained.

• Debrief - talk through your experience in detail with someone you trust to listen. Explain what happened and how you felt at every stage. Writing it down may also help. Do this several times if you need to.

• Tell your partner what support you need. Do you need them to remind you that you are lucky to have a healthy baby, to tell you what they remember, or just to listen? Remember your partner too may have felt powerless or scared. They may feel unable to burden you with this, when you have been through labour and they have 'only' watched.

• Remind people who tell you how lucky you are to have a healthy baby when you tell them you are upset, that you know that's the most important thing, but the fact that you feel upset by your experience is also important to you.

• If you find you have negative feelings that don't seem to be going away, talk to your midwife, health visitor or doctor.

Dr Mary Lowth is an author or the original author of this leaflet.