Artwork by Amanda Greavette: http://www.amandagreavette.com
This post is about early labour and the mixed messages women are given about this important part of the birthing process.
Defining the indefinable
The concept of ‘early’ or ‘latent’ labour emerged as a result of the birth process being broken down into stage and phases – the diagnosis of which relies on clinical assessments of contraction pattern and cervical dilatation. The notion of being able to determine the future progress of labour from such clinical assessments is not supported by research, yet it underpins maternity care. What research does show is that concepts of stages and phases of labour does not align with women’s perception and assessment of their own birth process (Gross et al. 2009; Low & Moffat 2006; Dixon et al. 2012).
In addition ‘early’ is only ‘early’ with hindsight. At one point in time (the clinical diagnosis of early labour) there is no way of knowing if labour will result in a baby in 30 minutes or 24 hours. If a labour is 2 hours long… when did early labour occur? As previously discussed an individual woman’s body is unique and so is her labour pattern.
Labour is basically the process by which a baby moves from the inside of a woman to the outside of a woman. Sounds simple, but it is incredibly complex and involves a complicated interplay of physiological, psychological and emotional factors. Women’s experience of labour often involves a sense of separation from the external world, focussing within, and becoming immersed in the act of giving birth. The hormones released during birth support this ‘altered state of consciousness’ (see the work of Sarah Buckley). During early labour the woman is beginning to move into this birthing state. Many midwives, including myself use the changes in behaviour displayed by women as they move into, and through the ‘birthing state’ to estimate how close the birth is. Of course, just like clinical assessments this is not entirely reliable as some women do not follow the usual scenario.
Despite the fact that concepts such as ‘early labour’ and ‘established labour’ are constructed, and not very helpful… I need to use these terms in this post because they are used consistently in the literature I am discussing (apologies).
Hospital perspective: early labourers are not welcome
Women admitted to hospital in early labour are more likely to end up experiencing complications and interventions, including caesarean section (Klein et al. 2004; Bailit et al. 2009; Rahnama et al. 2006). There are two explanations for this:
- That these women already have a dysfunctional, prolonged labour which is why they are coming to hospital in early labour. This explanation is favoured by a local hospital, and their response is to augment (ARM and IV syntocinon) all women who are admitted in early labour who do not establish labour within 2 hours. The rationale is to avoid a prolonged, complicated labour… and according to the obstetrician ‘women don’t want to be in labour for a long time’. I wonder if the women are consenting to these procedures based on adequate information… or just being asked if they want a shorter labour (hands up!)
- That exposure to the routine interventions involved with care in a hospital setting increase the chance of complications occurring (Bailit et al. 2009) ie. the longer the woman is in the system, the more opportunity there is to ‘do stuff’ to her.
Women admitted to hospital in early labour also cost the institution more money because they are on the ward for longer which increases demands on services and staffing. Therefore, great efforts are made to deter women from settling themselves into hospital during early labour. Antenatal classes warn women to stay away from the hospital for as long as possible to avoid intervention. When women ring hospital to enquire about coming in they are advised to ”take a paracetamol, have a bath the ring back in an hour” (guilty). Women are also told to only come to hospital when their contractions are coming every 5 minutes or less – which is concerning because the pattern of contractions is not necessarily an indicator of when the baby will be born. Entire services have been devised (phone support/home visits) to support women to stay at home during early labour (Janssen et al. 2009). When women arrive at hospital they are subjected to invasive clinical assessments to diagnose ‘established labour’ before they are ‘cleared’ for admission to labour ward (Cheyne et al. 2008).
If a woman does manage to get admitted whilst in early labour she is considered a burden by staff. She is likely to be put in a room and checked on occasionally and referred to as ‘not doing anything’, ‘niggling’, ‘she should go home’, etc. The midwife who admits her will be questioned and ridiculed at handover. The midwife allocated to her will most likely also be caring for a woman in ‘real labour’, and that woman will take priority. This is not to bag hospital midwives… I’ve been there myself, and it is very frustrating dealing with a woman in early labour whilst also caring for 1 or more women in ‘advanced’ labour. Whilst not condoning the hospital perspective on early labour – I can understand it from a cost/staffing perspective.
Women’s perspective: seeking reassurance and safety
Findings from qualitative studies suggest that staying away from hospital during early labour can be challenging for women. It seems that women want to be in hospital. And the experience of being assessed as ‘not in labour’ and sent home can be distressing and result in women feeling unsupported (Baxter 2007; Barnett et al. 2008; Scotland et al. 2011). A study of first time mothers found that women experienced embarrassment when they arrived at hospital too early to stay (Eri et al. 2010). They also felt vulnerable when negotiating with midwives to stay. The need to be in hospital is not necessarily about needing pain relief or support. Cheyne et al. (2007) found that women wanted to be in hospital during early labour despite feeling that they were coping well at home. Some participants reported feeling uncertainty about the safety of their baby whilst at home. Carlsson et al. (2009) also found that women were concerned for the wellbeing of themselves and their baby whilst labouring at home. They identified the theme ‘handing over responsibility’ as the core category emerging from their data. Women were keen to transfer to hospital in order to hand over the responsibility for safety to midwives.
Another concern associated with staying at home during early labour is uncertainty about identifying when established labour begins. Women in Cheyne et al.’s (2007) study expressed concern about not knowing how advanced their labour was while at home. Beebe et al. (2006) also found that first time mothers struggled to identify the onset of active labour themselves. Women worried about going to hospital too soon or too late, and were unsure of how to know if their labour was ‘the real thing’. Their main concern about staying at home was not being able to have their labour assessed by hospital staff. In Eri et al.’s (2010) study women perceived midwives as ‘gatekeepers’ with whom they had to negotiate their credibility with in order to gain access to the hospital. Gross et al. (2009) found that women’s own assessment of how and when their labour began was varied and did not match midwives’ clinical diagnosis of labour onset. A study of first time mothers by Low and Moffat (2006) found that women were perceived as abnormal by hospital staff if their experience of labour onset did not fit clinical definitions. Themes identified from the data included ‘this is not right’ and ‘don’t trust your body, trust us’
Physiology and contradictory messages
Let’s take a look at physiological explanations for early labour behaviour. Like all other mammals, labouring women seek a private and safe place where they can avoid distraction and immerse themselves in the act of birthing. During early labour women seek a place to settle and ‘nest’. This makes perfect sense because the neocortex is still engaged and can slow contractions (by reducing oxytocin) in response to thinking, talking, etc. - the woman can think clearly and do the practical things involved in a physical move. Once the woman is settled and her neocortex is not being stimulated, increased oxytocin release re-establishes contractions. This explains why labour often slows down in response to the move to hospital. However, as labour progresses the limbic system takes over and it becomes more difficult – and dangerous from an evolutionary perspective – to move from place to place. The neocortex is suppressed and the woman is deeply in an altered state of consciousness. This is the women who arrives at hospital already ‘separated’ from the external world, nothing stops her contractions, and she is often unaware of those around her until after the birth. So, the need to settle into the birth place during early labour is a normal response to the physiology of the birth process. It is also common for women to call on the support of other women during labour – women they know and who they feel safe with – relatives, friends, midwives, doulas. Early labour is a woman’s signal to get settled somewhere safe and to gather her ‘women-folk’ around her.
What is considered a ‘safe place’ is influenced by the culture in which the birth is taking place. I am not getting into the debate of hospital vs home re. safety. One, because I am totally over it, and two because I am a slightly biased homebirth midwife. Here is a Cochrane Review if you feel the need to head into the debate. Women in Australia (and many other parts of the world) are urged to birth in hospital because the cultural concepts of ‘safe’ involve medicine and technology. The experts in birth are the people who know how to use the medicine and technology, and who can carry out clinical assessments to determine wellness and progress (Davis-Floyd 2003). This message begins in pregnancy as women undergo routine clinical assessments with an emphasis on professional experts providing reassurance of wellbeing. Women are also bombarded with fear-based media about the dangers of birth, and the hospital-based Knights in Shining Armour who will gladly rescue any Damsel in Distress (and her baby). Therefore, it is not surprising that women head for the safety of the hospital when they are in early labour. Our culture has replaced the home/birth hut + well known women-folk with the hospital + unknown medical staff.
The emphasis on hospital as a place of safety whilst also encouraging women to stay away results in some very contradictory messages and ideas (please note these statements do not represent my own views):
- We are the experts in your labour progress, only our clinical assessments can determine what is happening… but we’d rather you do not come in to be assessed, and instead stay at home not knowing what is going on.
- Trust us – we want you to have a good birth experience… but if you come in too early we are likely to create complications which will require intervention… so keep away from us as long as you can.
- We are the experts in your labour progress, our clinical assessments can predict your future labour progress… we will send you home if you are found to be in early labour… if you then birth your baby in the car park it is not our fault as birth is unpredictable.
- This is a safe place to labour…. but you can only access this safety when you reach a particular point in your labour… preferably close to the end of your labour i.e. you should do most of it on your own away from safety. This contradiction results in a very annoying double standard: A women who labours at home and comes into hospital ‘fully and pushing’ is praised – ‘she did a great job’. However, she laboured (perhaps for many hours) without the attendance of a professional and without any monitoring (eg. fetal heart rate auscultation, etc.)…. On the other hand, a woman who homebirths intentionally is considered to be doing something unsafe despite the constant attendance and monitoring of her midwife.
Suggestions
Rather than considering ‘how to prevent women in early labour being admitted to hospital’, instead it may be better to explore how women’s needs during early labour can be accommodated by the maternity system. I would be interested to know what your experiences and/or suggestions are. Here are some thoughts, as usual I’m ignoring constraints of the system and money in favour of fantasy:
- Antenatal care should centre on building self trust and reinforcing the woman’s own expertise in birthing her baby. If she relies on herself to determine wellbeing and progress she may be less likely to head to hospital early for reassurance. A study by Carlsson et al. (2012) found that first time mothers who managed to remain at home during early labour expressed a sense of power. Maintaining power was the central focus for these women and involved a sense of authority over their own body. Something to be encouraged I think!
- Give early labour respect. It is an important part of the birth process and women deserve recognition for it… ie. don’t use the term ‘latent’ or ‘not in established labour’. The woman has begun the birth process. She has her signal to seek a safe place – help her do this.
- Women’s access to their birth space should not rely on them meeting arbitrary measurements which involve invasive clinical assessments. They should be able to use early labour to get to their ‘safe place’ and settle for birth.
- If you are planning to head to hospital while deeply in the altered state of labour – it might be useful to take along a doula who can advocate and use her neocortex while yours is suppressed.
Of course if a woman is birthing at home with a known and trusted care provider it is a different kettle of fish. She doesn’t need to concern herself with ‘when to go to hospital’ – and her care provider can (should) attend based on when the woman needs her… not when she meets particular criteria. Then again in the real world not all women want to birth at home, or can get the support to do so. Therefore, the systems in which they birth need to change. The essential problem is that maternity care has developed in response to the needs of institutions – not the needs of women. More research is being done… and reports published about what women want from their maternity system. Unfortunately what they want (woman-centred, continuity of care) is the opposite to what is already deeply embedded in our society (hospital-based, fragmented care). To turn this around is a huge undertaking… and change will undoubtedly meet resistance from those who benefit from the way things are.
Another brilliant piece. My only addition would be
3. Hospitals I have worked in do not have enough staff to provide one to one care for all those deep into their labour and this is another reason why women are discouraged from attending early in the process.
Bring on continuity of midwifery carer. Bring back knitting to the birth room. Sends a peaceful message that all is well and midwife is with you and not worried about anything.
Yes – I have edited a little to make this point stronger. Most hospitals are short staffed. And yes – the answer is continuity… and knitting (or crocheting)
another nice thing would be to have a dedicated dom midwife to do home assessments of women in early labour…. remember money was no object??
Yes but the problem with home assessments is that they are inaccurate as hospital assessments. A midwife might turn up and examine you – determine your cervix is 2cm dilated and diagnose early labour. A hour after she leaves you could birth your baby. The assessment are a false reassurance. The research about home visits is that they keep women home for longer but don’t reduce the rate of complication or intervention one the woman goes to hospital.
Hi Rachel.
First of all, thank you for a fantastic blog! You are an inspiration to me.
The subject in this post is so very relevant also in DK, where women need to travel a long way to get to their place of labour/birth. Unless off course they choose a birth at home. I have always felt a great resistance to the discourse on women being, or not being, in “real labour”. A discourse, which in my opinion is made by the system (hospital/midwifes/doctors), neglecting womens experience on same matter. Things need to be reconsidered and reconstructed in order to chance that. Therefore, we are some midwifes who are thinking about undertaking a small project on home visits where I work in Denmark.
I wonder if you would be so kind to write/post some references to the research you mention above about home visits?
Many greetings
Iben Nielsen
Hi Iben
If you click on the Janssen et al. ref in the blog post it will take you to a source
Many thanks for this post. It expresses superbly the problems described to us from many women on our helpline. A number have described to us practical difficulties about being sent home, including living a long distance away, with difficult journeys, lack of availability of drivers, and so on.
And then, of course, there are the cases when the assessment is wrong, resulting in BBAs, with added risk and psychological trauma. With best wishes,
Jean Robinson, President, Association for Improvements in the Maternity Services
Sounds like you will have to open a B&B&B bed and breakfast and baby ! A group of motel style challets where folk can spend their week long latent phase using as much Entonox as they like having a professional on hand to reassure and listen in occassionaly etc. You could have a team of masseurers and water papulers on site. Get investing in property close to the hospital now, it won’t be funded by the national health care providers! There’s a fotune waiting to be made out of this idea of yours.
Mel – I’ll be doing nothing of the sort. The women I work with birth at home and usually don’t need me until they are well into labour. They trust themselves and know I’ll come when needed. As for the hospital system… Due to running on empty the current situation will continue. There are no resources to provide care in long latent phases labours with women who are conditioned to need the system. However the private health system over here might follow your suggestions if there is money to be made… And massage + entonox may appeal to some.
Relevant post! And yes the women deserve recognition for being in “early labour”. This is part of the natural birthing process even though there might be different perspectives on this “phase” depending on if you are the woman herself, the midwife or an obstetrician.
I laboured at home for 8 hours with my first before going into the hospital. The midwife said to come in and we could “check your progress” and if I was far enough along I could stay. We lived 45 minutes away. On arrival at hospital, ARM , and labour went from being manageable to intense, pethidine administered. I could stay. Baby born around 7 hours later. Second time I told the (different) hospital that I wouldn’t be coming in until pushing. Midwife remarked that if I could get that far on my own, I probably didn’t need them anyway. I had prodromal? labour for around 2 weeks. Contractions starting mid afternoon, and increasing in frequency but not intensity, fizzle out around 9pm. Day of birth, laboured at home for 2 hours, called hospital, they said come when you feel ready, I went straight in as I felt “ready, only to be ridiculed by midwife that it was way to early, even though my contractions were 2 minutes apart. One intense long one, followed by a short, gentle one. Baby born 1 hour 45 min after arriving. (all 10p 8oz of him)… I’m commenting to illustrate the difference between going in to hospital under hospital instruction or going in under your own steam. First experience involved unneccesary intervention, second, no intervention required. Next time I’ll stay home, as I did find the transition to hospital, very intense and stressful. With such a quick labour, I really needed to be focussing on that and not answering questions and fending off a rude midwife. Personally, I feel a system like that of NZ would be much better. If you are in early labour, your midwife could come to your home and see to you. If you are intending on a hospital birth with her, she can help you to determine what the course of action should be. Anyway sorry for the long-windedness!! Another great article Rachel.
Thank you for sharing your experience. ‘Prodomal’ labour is common and just another label used for women who don’t fit the prescribed labour pattern. I have found that women who labour this way ie. stopping and starting over days/weeks often birth very quickly once their contractions get going. I think a lot of work is done during the ‘prodomal’ phase. But we only measure one indicator of progress – what the cervix is doing.
Once again Rachel, you write with thoughtful imsightful care. Understanding the hospital culture as well as compassionate understanding of the mother meets the two worlds together. THIS is why I choose you to help me in my journey. I always knew, that should I need to transfer, you would stand in that gap for me and advocate independent of the system holding either of us to ransom. You are one of a kind, and I am so proud to have the very sweet bond I can claim with you. Much love Rach, you are such an inspiration to so many.
Thanks Bel
xx
I’m sure some people would argue that I have never been in labour, despite labouring hard for 36 and 20 hours respectively with my sons. Both labours were similar, no warm up, no prodromol labour, the first contractions with both signalled the start of “it”, from my perspective. Contractions came every 2-10 minutes throughout, never really settling into the “textbook” patterns but intense enough to make me stop and need to breathe through right from the start. Yet in neither labour did I dilate beyond 5cm. Both planned home births, the second certainly had no shortage of oxytocin, I was flooded with it and very much in an altered state of consciousness for parts of it. I strongly feel that the way women perceive their labours is very important. When I encounter the view that I was not in labour I feel undermined and I simply know they are wrong. I laboured, I worked HARD, both times and seeing as both births resulted in c-sections, I have to vehemently defend my experiences. Thank you for this insightful piece.
Holly, I have had very similar birth experiences to you so can completely understand. I believe I was in prodromol labour for a few days before the birth of my 2nd baby (born at 40 weeks + 15 days), however this was rejected by all midwives and consultants. Instead I felt like I was being difficult and a nuisance because my baby was ‘late’. I too laboured long and hard before the ‘emergency’ c-sections and yet get told ‘oh, you have never actually laboured’, this is so demeaning. If there’s a next time I’ll be hiring an independent midwife, doula and having a home birth. I really enjoyed this compassionate and insightful piece. Thank you.
Hi Amy, for my second birth I had an IM and doula. It was the best money we have ever spent, even though I still had a caesarean. The support was amazing and I would never dream of having been without them for that birth. My IM came into theatre with us and both were there with me in recovery, my doula was vital in getting breastfeeding started. I don’t plan on any more children, but if I were to have another I would want my IM there. It deeply troubles me that in a year’s time she and all other IMs in Britain, will no longer be able to practice as they do now
Holly and Amy – see my reply to Shara re. prodomal labour. Maybe this could be a future post?
You both laboured as far as I am concerned… full stop!
I had the unpleasant experience of family and friends telling me I only had 4 hours of real labor despite the fact that I say I was in labor for 78 hours (after water breaking). The non-hospital birth center I used told every mother not to request to come in until contractions were 1 minute long, 4 minutes apart, for an hour.
So even though I spent 3 days with labor picking up and slowing down, I didn’t reach those magical numbers until 4 hours before baby was born. Because of that, people say I was only in “real labor” for 4 hours. Even my mother remarked about how my labor was SO EASY compared to her 9 hours (with c-section) and I was SO LUCKY it was that short.
Despite having supportive midwives who worked with me despite several risks factors that would have gotten me a c-section in a heartbeat at a hospital, I was still terrified of being the “dumb” woman who wanted to go in too early. Even after an hour of insanely, ridiculously intense, long, close together contractions, and considering I already had 3 days of lighter labor behind me, I still questioned if it was “the right time” and kept waiting.
Thanks for sharing your story and again highlighting the impact of enforcing ridiculous notions about what labour is onto women.
Thanks for another insightful post. I’m a student midwife and it scares me how quickly I have adopted the prevailing attitudes of those in the hospital that I work. I have uttered the words “she doesn’t need to be here” and told women antenatally to stay home as long as possible lest they come in and we “do stuff” to them. Your posts always remind me why I’m getting into midwifery in the first place, for women, not to become another burnt out hospital drone (though I have to say budget cuts and patient loads aren’t helping! ). Thanks again, looking forward to the next post.
It is so easy to assimilate… and sometimes you have have appear to do so to survive. Keep focused on being ‘with woman’, keep thinking critically and keep your integrity. Women need you
I loved reading this, thankyou. I am not a midwife at all but I am a mum of two children and in 9 weeks due to give birth to my 3rd. Being a first time mum is so hard as you have no idea what is really established labour and what isn’t, you fully trust the midwives to tell you what is going on. I also had no family around and I was the first of my friends to give birth so had no idea what was real labour or not. I knew from antenatal classes that I should only ring the hospital when I was having contractions five minutes apart. Trouble is since 3am in the morning I was and so at 5am I rang the hospital. Was told to come in, but when I got there I wasn’t dialated at all. They asked me if I wanted to go home or wait, and I remember saying, but if I’m not in labour now how will I know when I really am, without it being too late? I was so unsure of everything and decieded to stay. I was left in that room all day alone, with the midwives only checking on me a few times. At 11am I was only 1cm dialated but was still having 5 mintue contractions, and so they tried breaking my waters unsuccessfully. At 1pm I was 3cm dialated, still 5 minute contractions. Still being left alone and me getting increasingly scared and anxious. At 5pm after another lady had given birth they came back in and decieded to give me the drip, oxytocin, to strenghten my contractions. At almost 9pm I gave birth but had a reatained placenta and started bleeding, was rushed to surgery.
When my second baby came I had breathless contractions since 1pm in the afternoon, at 7pm I went into hospital as I had contractions that had brought tears. However when I got in there they didn’t even check me unitl 1pm – when I was making the right noises! I gave birth 3 hours later. Both births I had no pain relief and had a panic attack with my second in hospital remembering the first birth. What made these both bad experiences for me was being left alone! especially with the 2nd as I knew from my pain where my contractions were and could feel my cervix dialating, but they wouldn’t even check me because I wasn’t making enough noise. I am in a different town now and again the hospital is half an hour away.
I had no family or friends around me and relied on hospital staff to tell me how I was doing and make me feel supported. This I think is one of the biggest issues that needs to be addressed. Mothers shouldn’t be made to feel alone in birth, it isn’t natural and the old community structure that we would have had is no longer there to help support us, so this support needs to come from front line staff. I’m sorry that was very long winded, hope it helps. Louise.
I loved your article, altho I had a great eperience with the hospital, however I was induced the only 3 things I found really irratating was I suppose he was the head doctor at the tiime told the midwives not to allow me to drink or eat anything because I would need a c section anyway which i thought was just plan rude mind you I did it all without drugs and had my daughter in just 7hrs start to finish (I was lucky), the other thing was I had to have stiches and was told to use the gas which I did for a little but it made me feel sick so I stopped then I had the lady who was doing my stitches kept telling me to keep still cause she thinks shes hurting me well I hate to tell her this but yes it was hurting then she just left my legs in the air and everyone left the room for handover I guess, I was there for an 1hr by myself door wide open so anyone could see in I was so embarrased, but other then that it was a good eperience I thought anyway
Reblogged this on Life begins at 30! and commented:
I love this woman! Another fantastic article. I particularily liked this quote:
” The woman has begun the birth process. She has her signal to seek a safe place – help her do this.”
Sums it up really
Thank you for this piece – it really resonated with me, and clarified some of my feelings towards my labour experience with my daughter (my first child). I had what was termed ‘pre-labour’ for around 6 days prior to my daughter’s birth day – some of the others here have made mention of ‘prodromal’ contractions, and having read up a little, I think these are what I had (i.e. very strong but fairly irregular Braxton Hicks-type contractions, peaking in intensity then fading off). The day of the birth, there wasn’t much activity in the morning – I then had an afternoon sleep, and woke up 2 hours later with painful contractions coming less than 2 minutes apart and lasting well over a minute. Cue speedy trip to the hospital, where they sent me to the assessment unit (despite my having two contractions while at the front admissions desk) – and where the midwife then insisted that I have an internal exam to ‘see how far along I was’. I refused the exam; the midwife told me that, as I was on all fours, she would raise the head of the bed ‘to keep the baby’s head on the cervix’ – and my waters broke. (I had done active birth yoga for months up to this point, and knew that head-down-bum-up would slow a rapid labour – but couldn’t articulate that at the time.) The midwife insisted again that she be allowed to do an exam, and I felt I had no option at that stage. The midwife’s next comment: “Oh, and there’s the baby’s head”. Through to birth suite, where my daughter arrived 10 minutes later after 3 contractions. (And we went home 4.5 hours later…).
Sorry for the long – but cathartic! – post… 
My experience taught me a few things – namely, my understanding of my own body and my interpretation of my labour experience wasn’t really trusted by the hospital system. And, secondly, I am committed to a home birth for any subsequent children, as the most confronting aspect of the labour and birth for me was the move to a place (the hospital) while I was in ‘transition’, and to interaction with people who were not in a position to really hear me when I said ‘I’m in labour and I am about to have a baby – get out of my way and stop interfering!’. Hindsight is always 20/20, I suppose!
Don’t apologise. I want women to share their experiences – it is a valuable resource for others
I am not a midwife and I’ve not had kids yet but I think about birth a lot. I have vulvodynia and for that reason want to refuse internals. I am really concerned because it looks like docs and midwives only use cervix dilation to measure progress. No other marker seems to be observed or valued. I also think for that reason, I am likely to be bullied every few hours because they want to fill out their charts and talk about “progress”. Should I just adopt?
You don’t need to adopt. No one can do anything to you without your consent. If you do not consent you will not be examined. I suggest employing a care provider who can assess your labour progress without using invasive internal assessments. They do exist
Cool! I am planning on going to the UK (where I am from) to birth and getting a private midwife. I live in Denmark and they have no compunctions about bullying patients. I’ve had a gyn shout at me and use sarcasm because I queried her diagnosis which contradicted what I had been told by gyn before her!! If I absolutely have to birth in DK, I’m getting a doula because they REALLY wind up the Danish midwives…
There are several ways to assess labor without actually putting ones fingers in the mother. Observing the mom,s behavior, noting fundal height in relation to the xiphoid process, and if mom is on hands and knees, looking for the”purple line” where mom,s butt crack is…
Yes – there is. My phd findings support this. Midwives used all kinds of ways of assessing progress – none of them invasive. This is what I use in my practice… but I am aware that such assessments are totally disregarded in mainstream maternity. Which is a real shame.
I feel fortunate that I am a midwife in a caseload model of care. I agree with your thoughts on ‘early’ labour and giving the couple education and power to trust in themselves and the process and be comfortable with the knowledge that their midwife is only a phone call away.I do believe it is the key to avoiding unwanted intervention….Some women however have sometimes ‘had enough’ and want you to do something! Uneducated family can often be problematic also.
After sending a woman home in early labour, the later outcome of a stillbirth has resulted in a local hospital insisting that all woman presenting in latent phase are admitted and monitored. My concern is that this WILL lead to increased interventions for these women, some of which may not be necessary. They are also separated from their families during latent phase which is stressful and while I agree that sometimes a woman is better off in her ‘safe place’, it should not be mandated that a woman MUST be admitted and not allowed to return home, reassured that everything is well. When anxiety levels rise, labour is often prolonged.
You make some good points and it would be great if every woman had a doula with her.
I find the knee jerk reactions to stillbirth interesting. No one suggests banning all inductions when a baby dies due to syntocinon induced placental abruption. Yet when the situation can be used to generate fear around physiological labour it is grasped. If you read my post I suggest women should have ‘access’ to their birth space. Not that they should be made to stay there. I guess the only answer in this scenario is to provide women with full information. They are actually free to leave. There is no law in place making them stay.
Not only is the blog informative so are the the posts. I want to see “Antenatal classes’ where women explore their herstory of birthing and what it has done to mothering as well as sharing with other women who have had positive birth experiences to counter the fear mongering. Obstetric approaches to birth lack logic let alone an understanding of physiology as they as based on ‘studying’ women birthing in an allien often hositle (to the birth hormones and wome) environment.
This is food for thought in light of my own experience. I had an unplanned homebirth for two reasons. First, my labour was fast and relatively painless so I thought I had more time than I did. And second, I found my safe place early on and it turned out to be my big four poster bed. Getting in a cab and moving to a strange room was the absolute last thing I wanted to do, so every time my anxious-to-transfer husband asked if we could go yet I said “Just five more minutes” until that turned into “Um, I can feel his head.”
So the only assessment I had throughout the whole journey was my husband saying he could see the purple line (which we learned about in antenatal classes) and taking a pic with his phone so I could see too. It never even occurred to me to wonder how dilated I was until a friend asked me after how I coped without this info. Honestly, my body was just on autopilot – numbers wouldn’t have had any meaning and I can see how getting hung up on them could even slow things down.
I plan to have a homebirth again if I have another baby, but I promise one thing – it will definitely not be unassisted. I owe it to the baby being born to have a healthcare professional quietly knitting (or crocheting) in the next room.
Hello, thank you for this post it is very relevant to an experience that I was recently had. I am currently studying to become a midwife. Part of my education is to follow a midwife and a few women through their journeys of pregnancy, childbirth and postpartum period. The most recent labour I attended was that of a woman who had planned to birth at home. The midwife, the woman and I spoke many times during her antenatal care about “early labour” and possible expectations, although as you say it is hard to quantify each woman’s potential experience to a set of standards or time lines for early labour. I see it as very important to be there for women when they feel as though they need the support from their midwife, however in this case the woman began calling on midwifery support on a Thursday night (while in “early labour”) and did not birth until Tuesday early am (“active labour” began Monday morning). This exhausted my abilities to provide the support I would have liked to throughout the whole experience as well as her chosen midwife’s abilities to do so and it was necessary to call a back up midwife. I am wondering if you have any suggestions in regards to this type of situation. I of course do not want to undermine women and their abilities to know when they want or need support, but also want to be able to realistically balance my care in regards to being present too early or late, and ensuring women feel sufficiently supported. Thanks so much.
This is a really hard one to answer. Women’s expectations of birth are influenced by culture (and media). They do not spend days waiting for a baby to arrive as a girl amongst the ‘women-folk’ and learn that the birth process can be very long for some. The only images of birth they see/hear are quick, dramatic births… or long disastrous ones. I can’t give you a ‘this is how to solve it’ answer. I can tell you what I do with the women I work for. I try to assist the woman to build her own self trust – that she doesn’t need me. I also make it clear that I don’t generally ‘do stuff’ ie. I am present but not doing – so getting me there early will not = me doing stuff to progress the labour. We talk about the birth process and how individual it is; we talk about the ‘what if you have a long build up and spend days contracting’… that conversation involves practical strategies ie. who will support her, how, what happens if I need to rest, back up, not getting too ‘into it’ too early ie. jumping about on a birth ball and going for walks to get things going… early labour is a time to sleep, rest, eat, focus inward… the importance of ‘being alone’ and undisturbed to assist with progressing into labour… the fact that me being there too early may distract her… however I will come when she needs me (so she doesn’t stress about needing me). To be honest. I find most women I care for don’t need me during a long early labour. I stay in touch with them and may visit and leave again. One woman in particular laboured on and off for 4 days, during which I attended another birth and did a postnatal visit. She was fine – just needed me to call in once or twice a day. She had a lovely baby in the end. I think some women who do calmbirth or hypnobirth can find early labour particularly challenging because they believe ‘this is it’ a lot sooner and start using all their strategies… that work wonders because they are in early labour. It can be difficult for them to understand that things are going to crank up a fair bit before the baby is close… just a personal observation. So those women can call the midwife sooner because they believe they are full on labour.
I think we also need to look after ourselves as midwives, negotiate our boundaries with women so there are no surprises. I think you just have to take it one woman/birth at a time.
With my first birth, I went in on a Wednesday because I had noticed some spotting and as a first time mom it kind of freaked me out. When I got there they hooked me up to the EFM and told me I was having contractions. I was like, really? I couldn’t feel them at all. That birth was an induction two days later for pre-e, but according to their machines I was in early labor that whole time. Our second son, we decided to do an unassisted homebirth. I was very surprised the morning I woke up with my water breaking (4 weeks early) and when my husband checked me he couldn’t feel my cervix at all. We only realized afterwards that I was already fully dilated at that point, but except for the intense contractions I had felt a week and a half before when I lost my mucous plug (minimal dilation at that point), I hadn’t felt any other contractions. Some might say I’m lucky, but the 3 1/2 hours of labor after my water broke were most definitely the most excruciating pain of my life. Personally, I would have liked a more gradual buildup (I think…) but I hated with the first one that they had to tell me I was in “early labor”. I know I didn’t feel like I was in labor until they started the induction, and with the second one my labor didn’t start until my water broke, but how does a woman fully dilate without labor? It’s definitely all very subjective, as much as the hospitals would like us to all fall in line and stick to their charts and graphs of what labor and birth is supposed to look like.
As a new doula, I am searching for ways to help laboring couples identify stages of labor and when to head to the hospital. I am finding that everybody wants to head to the hospital as soon as contractions pick up intensity with a sense of urgency as if they feel like their baby will fall out at any minute. I remind them of their goal to labor at home, reassure the partner that there will be signs of impending delivery and most important, tell them to head to the hospital if there is any anxiety about the welfare of the motherbaby. Couples have been content with this advice and continue to labor at home in most cases…after all, our local hospital is only 5 minutes away.
I chalked it up to our culture of birth as an illness that needs medical intervention and that the hospital is where they will get “help”. This has befuddled me as these are couples that are devoted to their natural birth plans and many desire to arrive to the hospital just in time to push baby out.
This post has given me MUCH to think about! Thanks so much!
you made some very interesting points and midwives i think tend to forget that labouring and birthing is an instinctive, primal, not a new way of birthing our babies. As a midwife we have been taught to assess early labouring women and either admit or sent home perhaps not placing as much importance on reassurance to the woman and her family. I feel we do forget about giving women the reassurance they need and the need to think outside the square as far as instinctive patterns/nesting goes. indepth education on the labouring/ body feeling patterns while the woman has still got her neocortex intact is what is needed. Thanks so much for the reminder!!!
Reblogged this on Full Circle Doula.
As a recent caseload midwife who has had many years in the hospital labour wards, I believe that women are smart. It is our language and empathy that allow women to accept that home is generally the safest place to be. It is not often the women but there partner / Family who say they should stay. Often careful explanation and reassurance will allow the women to accept that this baby is taking its time and often doing nothing is the best course of action. Not everything can be fixed in utopia by unlimited cash, space and human resources, sometimes women need to be empowered with knowledge and information and the reassurance that they have ability to endure what is ahead.
I totally agree. It starts with women being empowered. Hence my statement about antenatal education should be about building self trust. I also think continuity of relationship can help. I always ask to have a meeting with anyone who plans to attend the birth (relatives, friends, etc.) – usually at the 36 week appointment. That provides a great opportunity for a discussion about expectations and roles.
I really appreciate what one of the Student Midwife types posted about what if the time that the mother’s time of needing a midwife is days and days, how does the midwife provide care–and she said that they called in another midwife. That’s what you do. I am also a student midwife, and I was assisting at a planned out of hospital (BC) birth a couple of weeks ago. The mom appeared to be in transition, but then when the midwife did a check, her dilation was “only” 4 cm. After a full 50 hours in labor, she chose to transfer to hospital, received epidural for rest, and had a vaginal birth 5 hours later. We can have whole discussions about why the mom isn’t dilating faster, and “no change” has occurred over 24 hours, etc. The reality is that for some first time moms, their “need support” time is like 3 hours, and for some, especially if the baby has engaged acynclitic or is posterior, and they can have 72 hours of painful, intense, close together contractions while the babe tries to find the best way to descend… As care providers, how do we help our mothers understand the reality of *that much* variability in their labor, and honor that she might really need midwifery care–or at least doula care–for two or three days before the baby actually comes…?
See my answer to Student Midwife
These women are few and far between… but should be planned for. I would argue that an assessment of the cervix does not tell you how much change has occurred or will occur. I tend to assess progress by… this is going to sound wishy washy… I expect the intensity of the birth process to step up a notch once it establishes, and to continue stepping up a notch every few hours. I would worry about a woman having strong, powerful, regular contractions for many hours without any external signs of change ie. fundus moving down/changing, her stance changing, external signs of descent etc. However, if the contractions are typical ‘early labour’ contractions they can go on for a long time until the body has made all the subtle changes need to start pulling the cervix up and pushing the baby down. In the case you share – the woman went from 4cm to a baby in 5 hours – that is quick. It is a shame she had become exhausted in the build up, and I wonder whether she may have made a different decision and felt stronger if her cervix was 7cm? The cervix is only one measure of ‘change’ and not a very accurate one. It can be really hard for midwives involved in long early labours – and easy to find solutions in hindsight.
The more I read the less I want to birth according to my insurance plans plan. I went to a late labor course at the birthing center I’ve been ‘assigned’ to. I really want minimal to zero monitoring as everything I’ve read said that it doesn’t really do anything except to worry and confuse first time mothers when the baby’s heart rate drops naturally with each contraction.
I also recognized all of your statements from the tour. Don’t come until your contractions are less than 5 minutes apart. Don’t do this, don’t do that or we’ll send you home. The birthing center is 20 minutes from my house and I found this taxing that they may try to ‘send me home’ that 20 minutes but in the 20 minutes I could very well progress quite a bit and then still have a 20 minute return drive time. I’ve wanted to have a midwife assisted home delivery since finding out I was pregnant but lack of saved funds to pay a midwife has really cinched the deal to go with my insurance provider.
I’m 28 weeks pregnant now and may still be changing my mind and calling a few midwives to see if they have payment plans we can work out because the moment they told me that I have to lay still for 15 minutes every hour so they can ‘monitor the baby’ I just thought that was crazy. What if I didn’t want to lay still? Well they had a hook they could attach to the baby’s skull that could allow ‘moving’ monitoring. No thank you. It all just seemed highly unnecessary.
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I spent 5 days in labour (from Saturday to Wednesday) with my second son who was a drug free VBAC after my first son was born by C/S without labour. I experienced birth trauma with his birth.
I found my early labour was pretty easy to cope with until Monday night where I started stressing about looking after my eldest son while trying to birth a baby. Tuesday was a calm day that I spent relaxing with my IM and doula enjoying the time before active labour began as we’d sent my elder son to his nanna’s. I didn’t begin active labour until we went to the hospital on Tuesday night because I couldn’t relax into active labour until I was in my birth space. Once at the hospital labour progressed as to be expected for a first labour.
My IM and I knew I would have a long labour so we had talked about what she would need to be able to support me. When labour started I let her know and she checked on me a couple of times until I needed her there. She also made sure she got sleep and as I had doulas as well she knew I was being supported even when she wasn’t there.
Yes I had a long labour but I wouldn’t change how it went as it progressed at the pace I could cope with. Knowing my body was working to gently bring my body into active labour meant I never stressed about rupture and I had time to get my head around the concept of actually birthing a baby considering how hard I had worked to overcome the previous trauma.
Early labour is an important time in the birth process and shouldn’t be rushed or discounted. It is a time to get to the birth space and into the right head space for birth, and this should be respected.
I spent 2 days experienced extreme birth trauma with my first birth it was awful pain they gave a injection but this didn’t help me. it wonderful to read other people stories but it reminders of the pain
Fantastic article. having had 3 different hospital birth experiences i could relate. the difference and the experience of arriving on the point of pushing, not knowing my attendants…and then going in early and being treated like a time waster…all your suggestions are fantastic.
THIS ARTICLE MADE ME CRY. Out of all articles I have searched, for in what I experienced with a preterm delivery that lead to my pre-mature baby boys death, this one I heard a “voice”. Thank You and will keep searching for justice.
I am sorry you lost your baby boy. I hope you find the answers and justice you are looking for x
My Heart breaks for you….. I don’t know what it is to lose a baby, but loving my babies as I do, I don’t want to ever have to experience my imaginings of what it might be like. I wonder what your story is. What part of early labour and mixed messages touched you? I hope that you find peace. If you need to tell your story to find peace, then I am willing to hear it, so please tell us. I know part of the healing I experienced from my first c/s was by telling my story to people who cared. I hope that either in person or online you are able to find that support. Bless you mamma. May you find peace xxxx
I felt really confused about my labor because it was off and on and i knew this baby was coming but labor would stop once I arrived and I found out I wasnt even dilated that far.. later on that night I had constant pain and I wanted to be there because I thought what if something goes wrong… I have no one here to tell me im okay and my DH was already tired of the hospital trips that week so I had my MIL and DH who were tired and it wasnt quite helpful. I ended up finally being a 3. I was being told what was going on, instead of asking my permission, I felt like I didnt have any rights to questions and I also felt ashamed for being on medicaid so maybe mentally I wasnt prepared. Doctor broke my water knowing baby was an OP position and didnt bother to help. 3 out of the 4 nurses was helpful that had the monitor so tight on my back it made labor worse. I didnt know I was given potocin or after i started swelling they put that internal monitor in and I knew but I did know if that makes sense its like your being told at instead of making sure you know and being asked if you understand in a tone that makes you feel like you shouldnt question. I did end up with all of the cascade of interventions maybe because I came in early but I did have an OP baby but i felt if he would have shifted I wouldve had a quick labor instead I got a c-section and Ive always been afraid of hospitals and this didnt help and DH is against homebirth but now i know better just get a doula and a hospital CNM or a good OB and im just am going to labor at home and trust my body because mentally even though it wasnt the idea tramatic experience it was for me and I hated the vaginal exams and somehow I felt scarred from that. Maybe mentally someone forcefully shoving their fingers in a place that is sacred to me. I hope this helps I was the typical 1 in 3 I suppose and the c-section was reccommended I never asked why or if it was an emergency I shouldve. Still trying to come to terms with that.
Shouldve added this did happy at a baby-friendly hospital and the nurses were great and awesome but I dont think the term baby-friendly applies to doctors because they dont tend to use it.
You were in a vulnerable position and people took advantage of that and in my opinion assaulted you. I am sorry you experienced this abuse. You have every right to feel how you do. I hope you find some healing. If you haven’t already read it, my post on OP might help you understand that your body/baby were not ‘wrong’… you just needed support and time.
http://midwifethinking.com/2010/08/13/in-celebration-of-the-op-baby/
I have read all of the articles and the op one they were very helpful and I know it is likely ill have another op baby in the future I just hated those words that my mother in law said maybe he was too big for you to push out no I wasn’t given the time and that hurts the most hearing other ppl make excuses but I’m learning advice became a birth junkie lol but I will keep these articles in mind and get doula and a midwife for the future we an only learn more and with this birth movement happening rapidly due to technology and mothers banding together I believe the system will change quicker and put medical personal in their place about birth and change the system
I agree entirely with what you are saying. As a paramedic, I have seen it happen many times – from the woman who ends up birthing at home with the midwife unable to reach us in time (and sometimes we are unable to reach her in time), to the woman giving birth in her car. And all because they were sent home, encouraged to stay away or made to feel a burden when they came in. From my perspective, I have also rung labour wards as a paramedic and been asked to put the woman on the phone who, instead of being helped and encouraged in her labour, was “told off” for wasting resources. I am now just beginning to see it from the other side – as a pregnant first time mother I am unsure how labour will feel and when to ring.
I would like to stay at home for as long as possible as it is where I feel safe and comfortable. Oddly (in contradiction to some of your article) I am being told I MUST be in hospital as I am having an induction at 38 weeks. I have been told they will insert a pessary and leave me for 24 hours. I would love to go home, relax and let things progress in my own environment. I feel safe there: I am surrounded by my own things, I live 10 minutes from the hospital, my partner is an experienced A&E nurse, I am hoping to Hypnobirth etc. I am being told, however, that they want me in hospital from the time the pessary is inserted to the time of delivery! I’m looking at a very boring and uncomfortable day roaming the corridors I think….
Do you mind me asking why you have been advised to be induced? The language you use in your comment suggests that you have not been given a lot of information or opportunity to make informed choices for yourself. Induction may not be the best thing for you and your baby, but if it is you do still have rights and choices. I would strongly suggest you contact AIMS, they can help guide you to evidence-based information and help you to remain in control of your body and birth. You can email them: helpline@aims.org.uk
Your situation is a little different to the usual scenario. If you are being induced at 38 weeks there must be concerns that your baby is at greater risk staying inside than the risks involved with induction. Because the hospital is intervening to start your labour they need to ensure that they monitor their intervention well. They used to send women home after prostin pessary to wait for labour… but there were a few cases of stillbirth related to this so the practice stopped. There are potential side effects associated with prostin (http://www.drugs.com/sfx/prostin-e2-side-effects.html) and if you have medical concerns + undergoing the induction process it is probably wise to stay in hospital and be monitored. To be honest first baby and 38wks – it will mostly likely be a long and difficult process to get you into labour. Not sure if you’ve seen this: http://midwifethinking.com/2011/07/17/induction-a-step-by-step-guide/
Good luck and enjoy your baby!
This post changed my life. I was intrigued that there are no “stages” of labor. I had had four births with NO “urge to push” and I always wondered why I was missing a “stage” of labor. With this birth I gave myself permission to push when the nurse said I was only 5+ cm, I did so because my contractions were so intense that there was no break in-between. I gave one little test push just to check and it felt exactly right. My body was saying “yes, thank you!” This is biofeedback is so much more important than what a nurse says your dilation is. I pushed when I felt overly intense contractions and then they eased up. My baby was born after about 45 minutes of contractions where I pushed with no birth attendant, I never felt an urge to bear down, but pushing did feel right, the midwife only arrived in time for the last three contractions. With all my other births I have waited 2-10 hours after the intense contractions on top of each other phase before I pushed and it never, ever felt “right”. I did this because my midwives/nurses told me I wasn’t fully dilated or they wanted to do a shift change or there was a cervical lip, or I was still at home, or several of the above. The result was that pushing always took 2-4 hours, required a circus of coaching and usually caused tearing. This time pushing was easy and no tearing, the baby was my biggest yet.
I would appreciate your comments on women who come into hospital, and who are not in “established” labour (according to the midwives), but they are in extreme pain. In general, these women are denied effective analgesia. An occasional one may receive im pethidine, but anything more effective (iv fentanyl or remifentanil, or an epidural) is a big no-no! I would point out that I am a consultant anaesthetist with over 35 years obstetric anaesthetic practice under my belt. I have been involved (medico-legal opinion, or colleague support) in several cases where women were denied adequate pain relief when not “in established labour” and these women then went on to develop PTSD. This is an unacceptable state of affairs. Personally, I see no reason why such women should not have an epidural (the women I have been involved with have asked for that, but it was denied by the midwives). I know of two cases where the obstetrician was phoned in the middle of the night and “put on the spot” by the anaesthetist. In both cases the obstetrician eventually conceded that there was no logical reason to deny these women effective pain relief. An epidural is not committing anyone to deliver these women within a “fixed time.” In other aspects of anaesthetic practice we do “day case” epidurals for various reasons, or alternatively we leave epidurals in place for 3 – 5 days after major surgery. Thus, should a woman’s “non-labouring” painful contractions stop, and under “normal circumstances” she would have been sent home, Nothing is different with the epidural: the epidural catheter can be removed, and she is a “normal” woman again.
An interesting question/point. I agree with you. I don’t think it is up to anyone but the woman to determine her level of pain. And, if a woman is fully informed about the risks and benefits of an analgesia and wants it, she should have it regardless of what is going on with her cervix. As a community midwife I visited women postnatally who had had ‘normal’ vaginal births without analgesia and were traumatised because they had been denied analgesia despite asking. In hospital practice if a woman requests analgesia (more than once and between contractions) I get it for her… even though often I knew she will birth whilst I am drawing up the pethidine or on the phone to the anaesthetist. To be honest the biggest barrier I’ve experienced is that some anaethestists and hospital policies state that a woman’s cervix has to be 4cm dilated before an epidural can be sited – and some anaethestists refuse to attend if the woman’s cervix is 9cm + dilated. Considering the unreliable nature of assessing future progress via the cervix this is very frustrating.
In relation to induction – a lot of women want an epidural before syntocinon is commenced which is fair enough. So, why not in ‘non-labour’? Perhaps the cost implications – resources and staffing? Perhaps because extreme pain at this point in the birth process is not ‘normal’ and requires further investigation rather than medication? Perhaps because some women will have multiple admissions? Not sure. I’d be interested in other’s views here.