Transition is the name given to the stage in the last hour or two of the active phase of labour when you are nearing full dilatation (10cm) before you reach the second stage. You will only be aware of this if you have not had an epidural. It is a stage when you feel the contractions most intensely and you may decide you have changed your mind and want to go home and not have a baby!! This is a time when you really need support of your partner, midwife or Obstetrician.
You may become very irrational and start swearing and screaming for an epidural. If you are nearing full dilation, you would be ill-advised to get an epidural now as it may really slow things down and you may not be able to push baby out without the help of forceps or Ventouse. It could also affect your blood pressure adversely, having serious repercussions for your condition and the baby’s. In terms of practicality, there will not normally be time to call an anaesthetist, insert an epidural and for it to become effective before it is time to push!
The best thing to do is to suck on the gas and air and to try and appreciate that although the pain might feel like the end of the world, the birth of the baby is very very close and that the best thing is just to concentrate on breathing and staying as calm as you can.
Don’t be embarrassed by your behaviour during the transition stage. All the health professionals will have seen much worse! But do warn your partner about it.
In a natural labour, when the time comes you will know! There is no alterative and you will know what to do. The nature of the contractions change and normally most women will feel some intense pressure on their rectum and the desire to open their bowels and push down strongly. For many women this is automatic and instinctive. However, you can optimise your technique with your midwife’s support. Bearing in mind contractions last at least 45 seconds, it should be possible to do anything from 2 to 5 pushes in that time.
The best way of pushing is with a lung full of air, mouth closed with chin in your chest, using your lung of air as a piston. Some women describe this as like doing a massive poo. Some women are frightened or embarrassed by the prospect of doing a poo during labour but you should bear in mind that most women will have empty bowels by this stage, either because they have done a poo naturally at some stage or have used a suppository to help empty them. If you do do a poo whilst pushing, the likelihood is that you will not notice, and if you do notice, you will not care. The midwife will remove it discreetly and change the disposable bedding underneath you if it has made a mess. It is very important not to worry about this and not to let this hold you back from pushing effectively. It would be a shame to be so scared of pooing that you did not push properly and had to have forceps and an episiotomy. The staff will not be the slightest bit bothered by you pooing as they will have encountered it countless times before. It’s quite natural.
The position that you adopt for pushing will depend on many things such as your personal preference, whether you are being monitored, whether you have had an epidural, concerns about baby’s condition and the midwife’s preference (in certain positions the midwife can see better if you are pushing effectively).
For some women it feels natural to be on all fours. For others, lying on your left hand side can be more comfortable. Squatting or leaning against the bed or against your partner or midwife may also be comfortable. When the time comes, you will know what makes you feel best and your limitations will help decide what position you give birth in.
Long pushes are better than short ones. You should be aware that you might not progress with every contraction and every push. Sometimes the baby might move 3 steps forward 2 steps back which can be discouraging if you are trying your hardest. But you should persevere, as this is normal.
Once the midwife or doctor is able to see baby’s head, delivery can be expected to be within the hour or quicker.
If your midwife tells you to stop pushing, (if she is worried that the baby might come out too fast and that your vagina may tear) then it can be helpful to pant rather than deep breathing.
If you have had an epidural you do not need to start pushing as soon as you are fully dilated- you may wait for an hour or so to allow the baby’s head to come down and to increase sensation to maximise chances of a normal delivery. Top ups of the epidural in the second stage of labour should be used carefully in order to allow the woman to have some sensation so she can feel to push and therefore play an active roll in the delivery of the baby. It is therefore advisable to let the epidural wear off a bit so she can push properly. This is obviously something that will only happen in agreement with the patient and the midwife. If the pain is too great then you may have to have more epidural top ups.
If you cannot feel anything then the midwife will tell you when to push- she will know when your contractions are coming and will let you know and guide you. You may be in pain and feeling scared or disorientated, but you should listen to the Midwife’s instructions.
The baby’s head should usually be visible after an hour of pushing if you are going to be hoping to have a spontaneous vaginal delivery. If it cannot be seen then the midwife or doctor will have to consider the use of forceps or Ventouse. See our section on assisted delivery.