What to Expect: Vaginal Delivery and Recovery

Expert Contributors:

Nola Herlihy, OB-GYN, and Kelsey Kossl, OB-GYN

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Every delivery and recovery is different, and of course, birth plans don’t always go according to plan. But if you know what markers to expect, the time from when you arrive at the hospital or birth center may seem less unknown, less intimidating, and easier to handle. There are three stages of labor. Here, we break them down.

 

First Stage of Labor

The first stage of labor is broken into two parts: early labor and active labor. During early labor, most women with uncomplicated pregnancies can labor at home. When the uterus begins to contract, these contractions (some women liken them to really bad period cramps) cause pain in the abdomen. In the beginning, contractions will be farther apart and erratic). As they progress, contractions become more frequent and more painful. “The definition of labor is regular uterine contractions leading to cervical change,” says Nola Herlihy, an ob-gyn based in New Jersey, who explains that contractions can start on and off for days or weeks before labor “but until contractions are regular and becoming really painful, we don't recommend coming into the hospital because it could be false labor.”

When contractions are two to three minutes apart or your water breaks, it’s time to head to the hospital. This is active labor—when your cervix dilates to 10cm. The cervix needs to both soften and thin to create the conditions for delivery. “The cervix is a tube,” Herlihy says. “During labor it expands outward and thins. Expanding outward is dilation, but the length of the cervix also becomes paper thin.” On average, your cervix will dilate about one cm per hour, so this process takes about four to six hours.

(If things aren’t progressing on their own, your doctor or midwife may intervene to expedite cervical ripening. Common methods—sometimes used in combination—include mechanical induction, in which a catheter with a balloon on the end, called a Foley bulb, is inserted into the vagina and inflated with saline solution to dilate the cervix. “Some patients feel nothing, some patients feel cramping,” says ob-gyn Kelsey Kossl. “The process of insertion does involve a vaginal exam, and I counsel women to be prepared for that, practice breathing techniques, and ask for breaks as needed.” The other option is labor-inducing Medication, like misopropal, which mimics the prosteglandin hormone that naturally occurs during labor and can be administered orally or vaginally. When used with a Foley bulb, inflating the bulb releases prosteglandin while also dilating the cervix.)

Note that the majority of women who are induced have their water broken by the doctor with a sterile instrument once the cervix is dilated. “A lot of what we're doing in terms of induction is getting the cervix dilated enough to be able to rupture membranes, because that’s often what puts a woman into a really good labor pattern,” Kossl says. “It’s that moment where everything clicks together in terms of getting a woman into labor.”

 

Things to know

  • Epidurals
    • An epidural is a nerve block agent that numbs or dulls the pain of contractions. To administer an epidural, an anesthesiologist will insert a small, flexible catheter into the spine (it sounds a lot more painful than it typically is), secure it in place with a wide swath of medical tape, and within about ten minutes, labor pains abate. An epidural will numb feeling from the waist down so patients who have an epidural are confined to their beds. Often, an epidural can slow down contractions, which is when your doctor or midwife may suggest Pitocin to speed things along.
  • Pitocin
    • "In terms of really starting the process of uterine contractions, there’s only one medication, and that's Pitocin,” says Herlihy. Once the cervix is ready, pitocin will be administered via IV to mimic the effects of the hormone oxytocin, which the body makes naturally when labor begins. You have officially entered the second stage of labor: “The first stage of labor lasts up until the cervix is fully dilated, and the second stage of labor is from the time of fully dilation until the time of delivery.” The former is considered latent labor, and the latter active labor. “Once you get to active labor, things really start to progress much faster. Usually within a couple hours you can expect to be at the phase where you're pushing,” she says. It’s common for an induced delivery to take 12 to 24 hours.

 

Questions to ask

  • When should I come in?
    • “Know who to call when you go into labor so they can guide you on whether you should stay home versus whether you should go in,” says certified nurse-midwife Kelly Levitt. They can advise on what to do during early labor—rest, take a bath, move around—and make sure you head to the hospital at the right time, not too early.
  • Is this back labor? How can I ease the pain?
    • Women who experience back labor—lower back pain that can be associated with the baby’s position during early labor—can ask about exercises like the Miles Circuit, which encourage the baby into the correct position.
  • What interventions do you do if labor slows down?
    • Ask what your provider’s approach to labor augmentation is. Some providers break a woman’s water, others use Pitocin, and timelines can differ. “Make sure you are a labor advocate for yourself,” Levitt says. “When they ask you a question or to make a decision, know that you can respond with, ‘I just want to think about it for a minute,’ or ‘can we wait on this?’”

 

The Second Stage of Labor

You’re ready to push out your baby! This stage can last a few minutes to many hours. (If you have had an epidural or it is your first baby, it usually takes longer.) Each time you have a contraction, your doctor or midwife will tell you to “bear down,” which means squeezing muscles you are probably not used to squeezing. You will be asked to push harder or back off slightly, and during this time both your vitals and the baby’s heart-rate and oxygen level will be constantly monitored. Once you push out the baby’s head, the body usually follows very quickly. Don’t be alarmed if your baby has a bluish tint—it’s normal!

Things to know

  • Episiotomies and Vaginal Tears
    • Years ago, doctors routinely made an incision in the tissue between the vagina and the anus—the perineum. This incision is called an episiotomy. But it fell out of favor among healthcare professionals in recent years because it is thought to be unnecessary. If the vagina tears during labor, your doctor or midwife may suture the tear (the stitches will be absorbed by the body) or if it’s small enough, simply leave the body to heal on its own.

 

Questions to ask

  • Can I change position?
    • Women aren’t always made aware of the different positions available, like side-lying or on hands and knees. “A lot of women with an epidural can still get into hands and knees, and these different positions can help reduce tearing.” Different positions can make delivery easier, so ask even if your provider doesn’t bring it up first.
  • Can I get perineal support during labor?
    • Massage and warm compresses can reduce perineal trauma, and even if you don’t bring your own supplies (like natural oil, lubricant, or castille soap), many hospitals can provide perineal support if you ask.

 

The Third Stage of Labor

After delivery, the uterus will contract until the placenta and the amniotic sac detach from the uterine wall. Women typically deliver the placenta a few minutes after the baby, but it can take up to 30 minutes. Delivering the placenta shouldn’t be too uncomfortable—it’s much smaller than a baby. “It’s about the size of a small Frisbee,” Herlihy says. If you plan to breastfeed—or even if you don’t—experts advise holding the baby on your chest for skin-to-skin contact as soon as possible to initiate bonding. Typically, a delivery nurse will massage your abdomen and you will start to feel contractions. This is your uterus beginning to shrink back to its previous size.

Welcome to the fourth trimester.

 

Questions to ask

  • Is it too late for pain relief?
    • “If you don't have pain medicine during labor, you can get local medicine for a repair after delivery,” Levitt says. Especially when there’s tearing, numbing medicine helps ease pain post-delivery for women that don’t choose an epidural.
  • How much skin-to-skin contact will I have and for how long?
    • You’ll want to know in advance if the baby can lie right on you after birth. “Skin to skin is huge,” Levitt says. “A lot more hospitals are doing what's called the golden hour, where the baby is on your chest for the first hour while being assessed, to help with blood sugar regulation, temperature regulation, and to initiate breastfeeding.” Ask if your baby will be assessed on your chest or in a warmer, and let the medical team know your preference.

 

After You’ve Given Birth

Things to know

  • Contractions
    • In the first two days postpartum, expect to feel the uterus contracting—especially if you’re breastfeeding. The same hormone that causes uterine contractions, oxytocin, is released during breastfeeding, causing painful (and often unexpected) contractions as the uterus gets smaller. “It certainly was surprising to me—even as an ob-gyn—how painful it was to feel those contractions in those first 48 hours,” Herhily says. Your perineum will be swollen after delivery, even if you didn’t experience tears or have an episiotomy. Herlihy recommends alternating between Tylenol and Motrin every four to six hours for 48 hours as your body recovers. Both medications are safe for breastfeeding.
  • Bleeding
    • For the first couple of days, postpartum bleeding, or lochia, will be bright red as the body sheds the uterine lining. “I strongly recommend a diaper,” says Herlily. “I know that's not what anybody wants to hear, but I wore them, and I don't have a problem saying that.” Thick maxi pads work too. Expect bleeding to be heavy for the first few days but call your doctor or midwife if you are soaking through one thick maxi pad in less than an hour or passing clots larger than a plum. After two weeks, postpartum bleeding, or lochia, will shift to a creamier or a pale-colored discharge with some intermittent spotting in between. Switch to lighter pads when you are ready.
    • Constipation
      • You may or may not be constipated as your body and organs shift back to where they were months ago. “Most women are sent home with a prescription for stool softener,” Kossl says. “It’s great to put yourself on a regimen of taking that once or twice a day, at least the first week.”

       

      Questions to ask

      • How can I get lactation support?
        • Many women leave the hospital before or right as breast engorgement starts, so knowing how to get in touch with a lactation consultant—whether it’s through the hospital or your pediatrician’s office—is important.
      • Do you have perineal care products I can use?
        • “Every woman should go home with a spray bottle and numbing spray,” Levitt says. Some hospitals will send you home stocked with everything from spray to pads to Sitz baths, but others don’t offer. You can usually take home everything in your postpartum room, so if they don’t offer, ask.