Searching for Clues: Five Alternative Methods for Assessing Labor Progress

Birth is a normal, physiologic process powered by strong muscle contractions of the uterus , facilitated by complex hormonal processes, and assisted by gravity and movement. To put it very simply, the cervix has to fully open to allow the baby to exit the uterus and pass through the vagina/ birth canal. At the same time, the baby has to navigate downward through the bony pelvis.

Cervical exams are routinely done throughout the first stage of labor to assess progress. This means a care provider or nurse is checking to see that the cervix is making progress toward fully opening to 10 centimeters and that the baby is making their way down through the pelvis. There are times when having this concrete information is beneficial or necessary. But cervical exams are invasive and can increase the risk of infection, especially if the amniotic sac has ruptured. There are other ways we can gather clues about how labor is progressing, like:

• Behavior cues
• Duration, frequency, and intensity of contractions
• Pelvic pressure
• Bloody show
• The purple line

#1 Behavior Cues

How a laboring person looks, sounds, and acts can give us some clues about which phase of first stage labor they might be in.

The first stage of labor, which begins when labor contractions begin and ends when the cervix is fully open or dilated, is divided into two phases:

• Latent phase 
• Active phase

It’s possible to assess labor progress by observing the behavior of the person in labor. There are some emotional signposts that give us clues about which phase of first stage labor the birthing person is likely in. These emotional signposts are also really valuable for you and anyone you’ll have supporting you at home before heading to your birth location to be familiar with. These clues can help you make the decision about when to head to your birth location (or have your care provider head to you, if birthing at home).

📝 Note: These emotional signposts are only accurate and relevant when the person in labor is not receiving medical pain management.

Latent Phase

During the latent phase of first stage labor, the cervix is dilating from 0-6 cm.

🪧 Emotional Signpost #1: Your behavior can provide clues about how labor is progressing. During the latent phase, you may be excited, chatty, anxious, nervous, and/ or restless.

An individual in the latent phase is still acting like their normal self. They are often able to rest or keep busy with other tasks. Though, this will get increasingly more difficult as this phase progresses.

Active Phase

During the active phase of first stage labor, the cervix is dilating from 6-10 cm.

🪧 Emotional Signpost #2: As you enter the active phase of labor, you may be serious, focused, quiet, less modest, and/ or more sensitive.

In the active phase, laboring people enter into a hormone-fueled altered state of consciousness, becoming more intuitive. They have turned inward and are less able to interact with those around them. Movements are slower and more deliberate.

As active labor progresses, contractions will continue to get longer, stronger, and closer together. This is usually the most intense and challenging part of labor. This last bit of active labor is often referred to as “transition”. It’s much harder to stay calm and relaxed. Additional coping strategies and support are often needed during this part of labor. If you’ve been coping well but start to feel like you can’t do it anymore, it’s a great sign that you are nearing the end. 

🪧 Emotional Signpost #3: As you near the end of active labor and approach full dilation, you may feel overwhelmed, confused, scared, full of self-doubt, and more vocal.

During this last bit of the first stage, individuals may act more primal and uninhibited. It can feel more out of control. Laboring people start becoming more alert and start to question their ability to manage the challenges of labor.

#2 Duration, Frequency, and Intensity of Contractions

The uterus is a muscular organ. During the first stage of labor, the uterine muscles tighten and release on regular intervals (contractions) that progressively increase in duration, frequency, and intensity. It’s a good sign that labor is progressing when contractions continue to get more and more challenging to manage.

If contractions slow down or stop, it could be a sign that something is affecting labor progress and that it’s time to consider troubleshooting potential causes.

#3 Pelvic Pressure

Individuals in labor will feel increasing amounts of pressure in the pelvic area as the baby descends lower. Rectal pressure and an urge to push are signs that the first stage of labor is coming to an end.

I still remember the pelvic pressure I experienced during my first labor. It grew more intense as active labor progressed to the point I found it very difficult to move. I needed a lot of support and encouragement when changing labor positions.

#4 Bloody Show

Bloody show is a common sign that labor is imminent. It’s blood-tinged mucus that comes from the cervix as it starts to change and prepare for labor. It’s also possible to see a second bloody show during active labor, which can be a sign that labor is progressing.

#5 The Purple Line

A purple line can be seen starting at the anus at the beginning of labor, and it extends upward as the cervix dilates. By the time full dilation has been reached, the purple line has reached the natal cleft. 

This line can also be red or brown. It can be very noticeable, faint, or not visible at all. It depends on skin color, with it being harder to see on darker skin.

🔗 The Red/Purple Line: An Alternate Method For Assessing Cervical Dilation Using Visual Cues | Lamaze International

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It’s important to understand that cervical exams and these alternative methods give us information about how labor has progressed so far or how it is going in the moment. We can never know the full birth story in advance.

If you’re interested in limiting or avoiding cervical exams during birth, talk to your care provider in advance about using some of these alternative methods. Find out which alternative methods they typically use or if they have any not on this list. Typically, midwives are more skilled in using these alternative methods, as normal, physiologic birth is their area of expertise. They also tend to be much more present during the first stage of labor than obstetricians.