As a practising NHS midwife, I spend most of my working life caring for women who are in established labour. It is often exciting, challenging, unpredictable and incredibly rewarding. Every labour is unique, so while no guide can tell you exactly how your labour will unfold, understanding what usually happens can help you feel more prepared and confident.
In this guide, I'll explain how to recognise established labour, when to contact your maternity unit, and how midwives assess whether labour is progressing.
What is established labour?
If you've read my guide to the latent phase of labour, you'll know that early labour can be unpredictable. Established labour is usually a little different: it is when labour settles into a more regular rhythm, contractions become stronger and more consistent, and your cervix continues to dilate.
Established labour is when the cervix is opening (dilating) from about 4cm (some hospitals say 5cm or 6cm) to 10cm (fully dilated).
At this stage of labour, contractions are consistent and regular, coming 3 to 4 times in every 10 minutes, lasting about 60 seconds, and so strong that you are unable to talk comfortably through them but instead have to focus and breathe through them.
What should I do when I think I am in established labour?
Unless you are planning a homebirth, most women are advised to go to hospital when they think that they might be in established labour so that they and their baby can be assessed and get closer monitoring. When you go to hospital, remember to bring your hospital bag and birth plan if you have one.
If you are planning a homebirth, call your midwife and they will come and assess you at home.
How can the midwife assess whether I am in established labour?
There are a number of ways that midwives are trained to detect whether you are in established labour, or whether you are still in the latent phase of labour.
Firstly, your midwife can observe your contractions
In the latent phase of labour (early labour), your contractions are generally characterised by being irregular - they vary in length and in strength, they may come every 5 minutes and then every 20 minutes, and they may even stop altogether before starting again. Whereas in established labour, your contractions become much more regular, coming 3 to 4 times in every 10 minutes, lasting about 60 seconds, and consistently strong.
Secondly, your midwife can offer you a vaginal examination
A vaginal examination involves the midwife putting two gloved fingers into your vagina and feeling for your cervix to see how much it has shortened, how much it has moved from pointing towards your back to your front, and how much it has dilated (opened).
Some hospitals say that established labour starts at 4cm, other hospitals might say 5cm or 6cm. Findings from a vaginal examination should be seen in the context of your contractions - for example, if you are 4cm but not contracting regularly, you may not yet be in established labour.
A cervical examination only provides a snapshot of one moment in time. It tells us how your cervix feels at the time of the examination, but it cannot predict what will happen over the next few hours.
... a midwife's insight
Vaginal examinations are not compulsory. If you do accept a vaginal examination, Entonox (gas and air) should always be offered to you. If it is not offered, ask your midwife, and it should be made available to you.
Thirdly, your midwife can listen to how you feel
Women normally know their body well, and they know themselves. So listen to your body, and if you feel that you are in labour, tell us! This is as important a sign as any, and we will listen.
What should I expect when I am in established labour?
Once you are in established labour, you will have one-to-one care with your midwife in a private labour room.
In the first stage of labour, your midwife will:
- Listen to your baby's heartbeat every 15 minutes, or you will be on continuous CTG monitoring, depending on your individual clinical situation
- Do your observations at least every hour (possibly more often if you are using the birthing pool)
- Feel your tummy for your contractions every 30 minutes to assess them for strength and length
- Encourage you to pass urine every 2 - 3 hours (having a full bladder can stop baby's head descending and prolong your labour, and cause bladder damage if baby's head does push down past your full bladder)
- Offer you a vaginal examination roughly every 4 hours to check your progress in labour (it is up to you whether you accept these examinations, they are not mandatory)
These checks are to make sure that you and baby remain well during labour and to help labour progress steadily.
How can I cope in established labour?
Once you are in established labour, you have lots of pain relief options available to you. These include all the methods that were available to you in the latent phase of labour (massage, water, TENS machine, mobilisation, breathing techniques and paracetamol), as well as the following methods of pain relief:
- Entonox (gas and air)
- Opioids (pethidine or diamorphine)
- Remifentanil
- Epidural
- Combined spinal epidural
... a midwife's insight
Keep an open mind when it comes to pain relief in labour - make sure you have thought about pharmacological and non-pharmacological options before labour starts.
Transition
You may have heard women being described as 'transitional' in labour. This refers to a time when a woman is coming up to being fully dilated, or is fully dilated, and in anticipation of the pushing stage, the body is flooded with adrenaline which can make the woman feel overwhelmed. You might find yourself becoming emotional and feeling out of control or like you 'can't do it' anymore. It is good to warn your partner about this, because otherwise they might worry! It is short lived (typically 10 - 20 minutes) and a good sign that labour is progressing well and that baby will soon be born.
What happens once I am 10cm dilated?
Once your cervix has opened fully, to 10cm, you enter the second stage of labour, the pushing stage. In this stage of labour, the baby is being pushed out of the uterus, into the birth canal and being born. But I will go into this in more detail in another pregnancy guide, as it deserves its own.
When to seek urgent help
Always phone your hospital if at any point:
- You have reduced fetal movements
- You experience any vaginal bleeding
- Your waters break or your waters are meconium stained (green or brownish in colour)
- You have constant pain between contractions
- You feel unwell
- You have concerns about yourself or your baby
A note from the labour ward
The most common question I get asked when looking after women in labour on the labour ward is 'how long will my labour last?'. I wish we could answer this question, but the reality is that it is often hard to predict. Generally speaking, first babies often take longer, and subsequent babies are often quicker. But labour doesn't always follow a predictable pattern, and that's completely normal.
Whilst we can't predict how long your labour might last, what we can do is assess how your labour is progressing, support you to cope at each stage and help you to make informed decisions if your labour isn't progressing as expected.