The most common question I’m asked when I’m with a woman in active labor is, “How much LONGER is it going to be?” This question is usually asked when the mom feels exhausted and is doubting her ability to handle one more contraction. She is hoping for reassurance that she will soon be pushing her little one out into the world.
While the dynamic of labor patterns can fluctuate during birth, there are some strong indicators that give us a good idea of how quickly labor is progressing and how soon the cervix will be fully dilated and the mom will be ready to push. Recognizing these signs is very helpful, whether you are supporting a mom in labor or whether you are preparing for your own labor and birth.
Most of the time, when a woman is in transition labor, she doesn’t want to be bothered with trying to decipher all the changes taking place, so it helps to have an observant person spot these indicators and encourage the mom as needed.
Contractions tend to have a wavelike pattern to them, where the sensation increases to a peak of intensity, then gradually eases away. This wavelike pattern usually starts off somewhat short, lasting maybe 30 seconds, and spaced maybe 10 minutes apart. According to the labor’s own timetable, the contractions will begin to occur more frequently and last longer. So, the contractions may begin to occur every 7 minutes, then 5, then 4 and so on…and they may lengthen from 30 seconds to 45 seconds to 60 seconds to 90 seconds long.
Noticing an increase in the frequency, intensity and duration of contractions (how close together they occur, how strong they are and how long they last) is a very important indicator of how labor is progressing. As the contractions become more frequent, stronger and longer, the emotional responses of the woman in labor change as well.
So, when the contractions are coming 2-3 minutes apart and are lasting 70-90 seconds and they feel stronger and more intense than at any previous point in labor, that is a very good indicator that the mom is getting very close to the pushing stage. To define this even more, look at the body language of the woman in labor and listen to her emotional expressions carefully. If she seems to be tuning out the rest of the room and is directing her focus inward, perhaps rocking and moaning, with eyes closed or with a distant look in her eyes, that is a good indicator of what I like to call “deep labor.” She will usually have difficulty answering questions at this point and may fall asleep in the short breaks between contractions. Then…very often, the woman in labor will begin to express doubt in her ability to give birth. She may answer every question, “I don’t know,” and may seem confused or express panic or desperation. While these emotions seem negative, they are actually a very good sign that the woman in labor is very close to the pushing stage.
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After you notice an increase in the frequency, intensity and duration of contractions (with an increase in the intensity of the woman’s emotions), you may then notice a change. The mom’s discomfort level may decrease and she may report feelings of intense pressure in her bottom area. You might hear a slight “catch” in her breathing or moaning, almost like a grunting sound. Sometimes, the contractions space out some (maybe only occur every 5 minutes instead of every 2 minutes). Those changes are a good indicator that the cervix may be completely dilated and she will soon be pushing.
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Something I have often noticed and husbands frequently point out is a bulging of the muscles in the very low back or sacrum area of the birthing woman. It can sometimes look like two half-tennis balls (maybe slightly deflated) under the skin in that area. If you put your hand on those contracting muscles there, they will feel very hard. Please use warm, moist heat and counterpressure to relieve discomfort in those contracted muscles. If the woman is having a burning sensation or a difficult painful sensation there, use an ice pack instead. The bulging muscles are possibly a result of the outward expansion of the pelvis (the wings of the ilium) as the baby descends. This may be seen not long before the mom starts pushing.
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Often prior to the start of labor, the baby will engage deeply into the pelvis (also called “dropping). When that happens, the mom may be able to breathe easier and she may notice that there is more space between her bra line (or breast area) and the top of her belly (the fundus of the uterus). Whereas before, she might’ve felt as though her breasts were practically resting on top of her uterus (and maybe they were!) and she might’ve only been able to squeeze one finger between her breasts and her belly…when the baby drops, she may have a space of about 4 fingers below her bra line before she feels the top of her uterus.
Toward the end of first stage labor (the dilating phase), you might notice that top of the uterus is now getting closer to the breast area again. When there is only about 2 fingers width between the bra line and the top of the uterus, the mom’s cervix may be dilated to about 8 cm. When there is virtually no space between the top of the uterus and the bra line once again, her cervix may be completely dilated (10 cm) and she will be pushing soon. (Please note that the “top” of the uterus is not the “front” of the uterus. So, I’m not talking about the belly button area, but the top of the uterus where it rises toward the breast area.)
I honestly can’t remember where I first read about this little sign, but I was immediately intrigued because the physiology of why that occurs made complete sense to me. (I explain this thoroughly in my birth prep series, but for those interested, here’s a short explanation: As the uterus contracts and pulls the cervix open, it also pulls the cervical tissue into the body of the uterus. The extra tissue collects at the top (fundus) of the uterus, making the muscle thicker there. This process is brilliant because the uterus then has a thicker band of muscle at the top to use as a piston while pushing the baby out. I decided to test this indicator as a sign of dilation with one of my moms and it worked! Without saying a word, I estimated how much space there was between the bra line and the fundus of the uterus, and when the care provider did a cervical check, my estimation was exactly right! It’s a sort of fun (at least it was for me), non-invasive way of estimating dilation and how soon the mom will be pushing. Some say the mom has to be on her back for this method of estimating dilation to be accurate, but I’ve observed it’s accuracy on a mom who was sitting in a birth pool, too. (To be most accurate, look at the fundal height during the peak of a contraction.) It is reportedly more accurate in women who have previously had a baby. (I’ve found that to be true, so far.)
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This is an interesting physical sign that can indicate dilation. It is simply the appearance of a purple line that starts at the anus and gradually shows up along the natal cleft (in other words, the butt crack). According to various studies, the longer the purple line, the more dilated the cervix. And yes, researchers have actually studied this. 🙂 When the purple line reaches the top of the…<ahem>…natal cleft, the cervix is (probably) completely dilated.
The Lancet (Byrne DL & Edmonds DK) published a study in 1990 that reported research by 18 midwives on 48 women. The purple line was visible 89% of the time. In a much more recent study in 2010 by BMC Pregnancy & Childbirth (Shepherd A, Cheyne H, Kennedy S, McIntosh C, Styles M and Niven C), the purple line was present 76% of the time out of 109 women studied. Interestingly, it was visible in 80% of women whose labors started on their own, but only 56% of the time in women whose labors were induced. http://www.biomedcentral.com/1471-2393/10/54
Byrne & Edmonds suggested that the cause of the purple line was due to pressure on the veins in the sacrum area as the baby descends. The thin skin in that area makes the line visible. The line may appear reddish in some women or simply as a darker line in others.
Some studies indicate that this method of estimating dilation is more accurate than vaginal exams. If you’d like to see an actual image of the purple line, this article in Birth Without Fear has some good illustrations, and this article in Science and Sensibility has a good image showing how to measure the line.
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Since many factors can influence the progress of labor, these indicators are not a guarantee that the pushing stage will soon begin, but they are remarkably accurate. If you see a few of these signs together, you can feel fairly confident that the dilating phase will soon be over.