It’s Go Time!

GoII

My couples are so concerned about when they’re supposed to go to the hospital. As a Childbirth Educator, you must cover this information early on in the class or they will freak out.

It’s good to remember this generation of birthing Mommas and their partners have grown up seeing birth portrayed over and over again on TV and at the movies and it’s always the same: The woman stands up in a very embarrassing and public space, announces loudly that her water has broken and then finds herself in gut-wrenching pain. She’s then rushed off to the hospital at break-neck speed, and then her highly-dramatic-and-fraught-with-complications birth comes to a speedy conclusion in about 30-60 minutes, depending on the length of the show.

There isn’t anyone in my classes who wants this birth to be their birth. So early on, we cover potential signs of labor: the “Your body is just warming up to the idea of giving birth” signs, the “Maybe/maybe not – I need more information, please” signs, and the “For sure, you’re having a baby” signs.

But for a lot of people, the most important question they have is – When is it “go time?”

I used to feel confident in replying to this question, but now it’s not so clear. Until about 6 months ago, I would have gone with the old standby of “5-1-1.” Which is to say, wait until the contractions get into a pattern of 5 minutes apart (measuring from the beginning of one contraction until the beginning of the next contraction), each individual contraction is 1 minute long (measuring from start to finish) and this pattern continues for at least 1 hour: 5-1-1. The idea behind providing them with this suggestion has always been to encourage women to do most, if not all, of their early laboring at home.

But since we’ve discovered that Friedman’s Curve for labor is obsolete (read much, much more about that here: http://evidencebasedbirth.com/friedmans-curve-and-failure-to-progress-a-leading-cause-of-unplanned-c-sections/) and we know that it takes today’s woman longer to labor and deliver their babies, there’s a new phrase bandied about the birth world: “6 is the new 4!”

For my first 15 years of teaching, we were basing our 5-1-1 instruction on outdated information! We used to believe that 4 cm dilation was the mark of Active Labor and that anything up to that point was considered Early Labor.

The significance of this change is real: we used to tell Mommas to hang out at home until you got to 5-1-1. When that finally happened, you could almost always count on having gotten through most of that early phase of labor. But now that we’re saying that 6 is the new 4, I’m pretty sure that 5-1-1 will not get a woman through most, and certainly not all, of her early labor.

The “powers that be” who are slow to provide us with updated posters and videos have not yet proclaimed a switch up from this model of 5-1-1. I’ve heard some individual educators switching it up in their own teaching, encouraging women to wait until 4-1-1 or even 3-1-1 – but I take issue with this as well.

For most first-time Mommas, waiting to get to 5-1-1 will seem to take forever! And they will be super ready to head into the hospital at that time. Waiting until contractions get to 4 or even 3 minutes apart, is asking a lot of our first-timers. These contractions are really close together and every contraction you have while driving in a car will completely suck – no matter how far apart they are. At 3 or 4 minutes apart, you’ll end up with even more hard contractions trying to make your way into the hospital.

Instead, I think we need to be explicit in letting them know how long it takes to birth a baby – especially first-timers. We should encourage them to be happy about Friedman’s Curve, because it will eventually translate into providers sitting on their hands longer and letting birth unfold as opposed to proclaiming “failure to progress” and getting all medical way too quickly. 

We should also help them set realistic expectations about what happens when “go time” finally arrives. I’ll often ask my students to do a little math when we’re talking about this time of labor. “How many contractions do you think she’ll have trying to make her way from the living room to the car parked in the driveway, if her contractions are coming at 5 minutes apart?” Most people answer, “1 or 2?” Sometimes I get, “Zero.” This makes sense if she’s just hanging out, but I have to remind them if she’s actually having contractions at 5 minutes apart, they’ve been lasting for a minute each and she’s been doing this for an hour, she’s not just hanging out – she’s in laborIt’s unlikely that she’ll jump up off the couch at the end of a contraction, grab the bag from you and skip down the steps.

Most women at this point will not be walking, talking or smiling at the peak of the contractions. She will be moving s-l-o-w-l-y. And she just might turn into a hot, weepy dependent mess. Why? Because it’s go time! This is not “false labor” and now, she has to actually push the baby out! Expect her to need a little extra TLC on the drive into the hospital. Drive safely, but as fast as the law will allow, because every minute she has to sit strapped into that bucket seat will be agony for her.

A woman in this situation starts to play this completely understandable, but totally off-base mind game. “Omigosh, these contractions are so much stronger than they were in my living room! Maybe when I get there, they’ll tell me I’m 10!” And this is where I think we, as Childbirth Educators, need to create realistic expectations about the initial check in at the hospital. Our couples need to know that if they have a contraction pattern of 5-1-1, that we’re keeping our fingers crossed for 3 cm when she’s checked for dilation.

Consider for a moment, what happens to the laboring woman who’s convinced that she’s “Just about to have this baby!” but is told, “You’re about 3 cm along.” It’s not good. In fact, it can be devastating! So this is what I tell my couples: The drive over to the hospital 3 is a lying, cheating, deceitful 3! And if you were still in your living room, you’d move through 4 and 5 and into 6 cm before it really felt super challenging. The 3 cm dilation that you think is 10 cm happens because all of your comfort and coping techniques get thrown out the window on the drive in. You’re no longer able to stand and sway to music, you can’t receive any massage or counter pressure, and your back is pressed into the passenger seat – a position that you would never willingly agree to unless there was heavy medication involved.

I want them to understand this is more of a mind thing than a body thing!  Because if they don’t, women start to doubt whether or not they’re capable of moving any further into their labor without medication.

And now, with 6 being the new 4, if there’s a request for medication soon after they arrive, it runs the risk of slowing things down and requiring other interventions to get the labor back on track. So, I’ve borrowed an idea from a YouTube video I saw a couple of years ago, to help ease a woman’s mind through that home to hospital transition time. 

Kathy Johnstone, a doula from Australia, says that the scale on which we measure dilation is completely whacked! She says that instead of charting 0-10 cm, we should really be tracking 0-20 cm – where the first 10 cm reflect the effacement or thinning out of the cervix and the second 10 cm reflect that actual dilation, or opening up of the cervix. This means we should add 10 to whatever number the nurse announces after doing the initial dilation check. 

Why can this be helpful? Because when a woman hears that she is 3 out of 10 cm along, that means she’s only 30% of the way done. But if she’s 13 out of 20 cm along, then she’s closer to 65% of the way done – and this is much more reflective of labor math. I’m all for whatever can help a woman’s mind make it through this time!

No matter what we share about the home to hospital transfer and the best way to negotiate that time and space, it’s most important that they understand that at 5-1-1, they’re not in active labor – not yet, at least. And that if they wish to have a birth that is low in interventions, they need to be prepared to do hard work at home and in the hospital to get to 6 cm dilation before they make any other big decisions about their births. I caution all my couples against getting into the labor bed after they’re admitted to the room – for at least an hour – so that their labor can get back on track before anything else gets added.

I’m still in this place of waiting to hear the proclamation, “Stay home until the contractions are 4-1-1 or less!” But we need to discuss not just “go time,” but also what to expect during the transition from home to hospital. It’s so important they have realistic expectations and are prepared to work in their labors – even if, maybe especially if, they’re hoping and planning on the epidural. If we’re still invested in all women working through their early labor unmedicated, they need to know this means they’ll be feeling lots of these contractions. They should all be learning as much as they can about non-medicated comfort techniques to help them continue to cope.

If they understand this, maybe it doesn’t matter so much if they go to the hospital at 5-1-1, 4-1-1 or 3-1-1.

It’s “go time” when their contractions are longer, stronger and closer together, their focus is entirely on the contractions, and at the peak of each contraction they are all business: no walking, talking or smiling. If these conditions are met, go on in to the hospital – it’s unlikely that anyone will be sending you home.

When you moved from home to hospital, how did you know it was time to go? In retrospect, did you go in too early? Too late? Or just right?

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8 thoughts on “It’s Go Time!

  1. The guidance I got was to come in to the hospital when I could no longer labor comfortably at home, and that worked for me (data point of one).

    This was amorphous and squishy and oh-so-frustrating ahead of time. I like numbers! I want a recipe, not a description of a meal!

    But when I finally went in to labor, I knew exactly when to head in. I had made that drive to the hospital for appointments. I knew how long it would take and not to wait too long because the drive (and the walk to the maternity ward–oh my god, the walk) would be too hard for me to cope. For what it’s worth, my labors were short (both about 7 hours and I was at the hospital for just two hours before my kids were born). I was also about 10 minutes away from the hospital for each birth.

    For women who rush it and come in too early? If they arrive at the hospital too early, based on the timing of their contractions? Scope out the hospital ahead of time. Find the quiet hallway with comfy chairs. Find the garden. Find the hallways you can walk (if walking is your thing). It’s ok to let your labor progress at the hospital before you formally check in. Find the corners tucked away in dead ends and behind pillars. You can give yourself that margin of error and time your trip to the hospital on the safe side such that you’re not in transit with rapid contractions and then settle in at the hospital itself. I don’t think it has to be an all or nothing proposition.

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    • Janice: I completely agree with what you’re saying here. I will tell people that it’s no good to stay home feeling anxious – you won’t be able to progress, so come in early and do exactly what you say here. The hospital that I work at now has a “healing garden” attached to the L&D unit which I think would be an absolutely lovely place to labor before being officially admitted! And the walk to the maternity ward? The hallways that seem to lengthen with each and every step? That’s what those wheelchairs are for! :O) Thanks for reading and leaving this comment!

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  2. With my back labor/day after day of hard contractions with little progression in the dilation department, it was hard each time to know exactly when to come in. I like the new recommendations/framework you explain here. It is such an intuitive process, from beginning to end, though, as you and Janice say, so many of us want formulas. 🙂

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  3. Man, as first-timers you want to nail it down to as specific as you can get it. My students don’t like it when I give them the 5-1-1 and THEN I talk about the outliers. Like you the slow-to-start days of working hard but not progressing contractions, or the equally intense super fast labor that doesn’t let go until it’s over. This is one of those areas where everyone just wants to be “average” and fall right in the middle of the bell curve. Telling them there can be variances to this theme is a hard one for them to get excited about! (Sorry you had back labor – I did with Elisa and it was AWFUL! I share your pain…)

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  4. Such a great post and great blog! I felt like I was ready to go when I started ‘dreading’ the car ride in. I was aware that if things got any worse, I may just refuse to get in the car! Ha ha ;p The contractions were beginning to overwhelm me and the pressure suddenly intensified to ridiculousness. Also the contractions began coming on top of each other, leaving me no time to mentally recover. With that in mind, I instinctively knew I was more than half a centremetre dialated! As it turned out, I was 5 centremetres dialated upon arrival, so that was good for me to hear! I felt like that meant I’d passed halfway and bubs wouldn’t be far off! 😀

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  5. You must have been SO happy to hear the number 5 upon arrival! The opposite is the worst – you think you’re almost 9 and they tell you “3”! So glad that was not the case for you! Thanks for reading and leaving your comments!

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