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Understanding the Signposts of Labor

Posted Apr 29 2010 8:13pm

For those looking to avoid routine interventions or put off pain medication, care providers commonly recommend staying home for as long as possible. This advice is very well intended, but the birthing mom’s partner will likely be called on to help make the final call about when to go in. That responsibility can be very overwhelming if he or she is unfamiliar with the sounds and movements of labor.

As a doula, I am well acquainted with the phone call when the partner says: “The last contraction was really strong - we are heading into the hospital NOW!” At this point, I usually ask if the laboring mom can come to the phone. I want to listen to her during a contraction and assess where things seem to be. One of the benefits of having a labor support doula, or anyone that is familiar with the mechanics of labor, is that they can recognize the “signposts” of labor and have a clearer idea of when to head to the hospital or birth center.

With that in mind, this blog entry is intended to help the laboring mom’s support team identify the signposts of labor.

Stage One of labor is defined as the cervix dilating from 0-10 cm and effacing (thinning of the cervix) from 0-100%. This stage is broken down further into: early, active, and transition.

Early Labor- 0-3cm
This stage may start subtly, with minor back aches or menstrual cramp-like feelings, and is often the longest. Contractions may start pretty far apart and last only 30-45 seconds. The mother may notice more of the mucus plug passing. As this stage progresses, the contractions will start to become more regular, longer, and closer together. The cervix will start to efface (thin out) more. This leads into the next phase: active labor.

In active labor, the mother may experience -Mild contractions, similar to menstrual cramps. These contractions are not so strong that you cannot talk through them if you needed to.
-Lower back ache
-Excitement
-Mild diarrhea
-Anticipation

During this stage, I recommend trying to ignore labor. It is so easy to get caught up in the start of the laboring journey, but you do not want to pull out all your pain management techniques too soon and be exhausted by the time you really need them. If labor begins during the night, try to keep sleeping. If it begins during the day, alternate between resting, a gentle walk or start a “labor project” - something that can keep your mind and time occupied as labor progresses. Bake some cookies for the nursing staff - it is nice to go in and make friends with them!

For the partner, I recommend keeping the laboring woman company and encouraging her to keep eating, drinking and emptying her bladder on a regular basis. This is also a good time to start organizing the belongings that will be going to the hospital or birth center. I also recommend giving a heads-up to the doctor, midwife, doula, babysitter etc.

Active Labor 4-7cm
During this stage the contractions are becoming more regular (5-2 minutes apart) and lasting about 60 seconds. There will be more “bloody show” (a mucus discharge that is tinged pink, red or brown), which is is a sign of cervical change. You will notice a shift in the mother’s mood; she will become more introverted and will be concentrating a lot more on her breath and her contractions. She may also need more support and pain management techniques at this point.

During active labor women may experience -Stronger contractions
-More intense backache
-Desire to talk less
-Mood shift to more serious and introverted place
-Apprehension and feeling unsure that she can do this
-Desire for support
-More “bloody show”

During this stage, the mother might turn her focus inward and will need to rely more on her pain management techniques. It will also be more difficult for her to talk through contractions. As this labor progresses, you will start to notice the sounds and the movements becoming more “primal”. If unmedicated, the mother will start to go into a pattern of movement that she finds comforting as the contractions build. Usually this position is a forward leaning one and is often accompanied by swaying of the hips of some kind. Many mothers start to use sound to release pressure, pain and tension. The sound may be sighs or low moans. When I see or hear this type of behavior, I consider it to indicate a “turning of the corner” from early labor to a strong active labor pattern.

The partner can best support the mom by helping her concentrate on her breathing, offering counterpressure or massage, helping her change positions and continuing to give her fluids. At this point she probably does not have the desire to eat. This is a good point to head into the hospital or birth center.

Transition 8-10cm

This is typically the most intense, but quickest stage of labor. Contractions are now 60-90 seconds long and occurring every 1-3 minutes. Fortunately, most women move through this phase in approximately 10-60 minutes. If the amniotic sac has not been broken yet, it will likely break in this phase or the care provider may offer to break the bag of water. During transition, the laboring woman will really need the help, support and encouragement from her support people.

During transition women may experience -Very intense contractions
-Nausea and/ or vomiting
-Rectal pressure and premature urge to push as the baby descends
-Chills and hot flashes
-Mood change, irritability, hopelessness, desire to give up, and self doubt
-Heavy bloody show
-Possibly even sleeping between contractions

If these physical and emotional “signposts” are evident and a home birth is not intended, I would strongly suggest making your way to the hospital or birth center at this point.

In unmedicated births, transition has its own distinct characteristics. When a woman who had found her groove and was managing active labor well, starts to get hopeless and even irrational, I can tell we are there. She will say things like: “I don’t think I can do this anymore,” or “I think I am done now - I want to go home”. This is a pretty good sign that she is almost ready to push. Other telltale signs of transition are the laboring mother expressing that she is experiencing a lot of rectal pressure or that she has a desire to vomit. She may have nausea, or hot/cold flashes, or even fall asleep between contractions.

If the mother seems really desperate and is starting to unravel, but needs to reach full dilation, I often suggest (if her water has not broken yet) that the care provider breaks the bag. The breaking of the water intensifies the labor and can give the mother that final push toward full dilation. Please note, I don’t recommend using this tactic earlier in labor.

Once full dilation is reached, the first stage of labor is complete.

The intention of this particular blog entry is for the partner to recognize the signposts of labor in order to help determine what stage of labor the mother may be in. So I will not go further into discussing the second stage of labor – pushing - or the third stage - the delivery of the placenta - since it is assumed that most women will have the help of a birth professional involved in the labor and delivery at this point.

Exceptions

As with anything else in life, there are exceptions to the rules. The two exceptions to highlight are the case of a posterior baby or a precipitous labor.

The first one, OP or Occiput posterior, is when the baby’s occiput is toward the mother’s back. This can cause tremendous back ache since the mother is feeling the baby’s occiput push against her sacrum. In a situation like this, the mother may experience intense back pain during contractions that are timing close together and even have rectal pressure. Identifying back labor can be confusing for most, since the level of discomfort the mother is expressing, as well as the close proximity of the contractions, are associated with active labor and progressed dilation.

Typically, OP labors are longer since the baby is not pushing the cervix open with the smallest part of their head, but instead trying to use their forehead. Should a labor start out as posterior, it is good to know that the incidence of persistent occiput posterior babies at delivery is about 5.5% . So the baby is likely to rotate anteriorly.

(For more information about posterior position- please refer to “ Explanation Of Fetal Positions “)

The second exception is, precipitous labor, which is a labor that from start to finish is under three hours long. In the case of precipitous births, the mother does not go through the stages of labor gradually. Instead, she feels the onset of contractions which will quickly grow in intensity and proximity. I admit, I have only seen this a few times during my doula career. It is estimated that only 2% of births are precipitous, and it is rarely the case for a first time mother.

While many mothers may read this and think: “Sign me up for a quick birth!,” a precipitous labor can be overwhelming for the mother since there is little time to rest and recover between contractions.
The mother will also need to rely on natural pain management techniques since there is no time for pain medication to be administered. On the positive side - generally speaking, when labor is happening very fast, the mother can rest assured that there is nothing wrong. Her body is working at peak performance in perfect coordination with her baby to make her labor and birth extremely efficient.

If a mother or her birthing partner suspects she is having a precipitous birth, it is advised to get help or get to the hospital as soon as possible. However, if the mother has progressed so quickly that she is already feeling the urge to push, DO NOT try to leave your home. This is when babies are born in cabs or the side of the road! Instead, call 911 for the EMT- they are well-equipped to birth babies.

“Alternative ways” to measure dilation

I can not take any credit for coming up with these alternative ways to measure dilation. My friend Kim, who has a blog, Doula Momma , wrote about these finds in one of her blog entries. I found these two methods fascinating and unusual. So here they are:

From Helping mothers give birth joyfully without fear. A doula in Israel

Measure your cervical dilation from the outside! Think about the shape of the uterus. Before labor, the muscle of the uterus is thick evenly around all sides, above, below, behind. As the cervix starts thinning and dilating, all that muscle has to go somewhere – it bunches up at that top. The top of the uterus thickens dramatically the more the cervix opens. During a contraction, at the beginning of labor, check how many fingers you can fit between the fundus (top of your bump) and the bra line – you will be able to fit 5 fingers. As the top of the fundus rises higher during labor, you will fit fewer and fewer fingers. When you can fit 3 fingers, I usually tell mothers they can think about going into hospital as they will find they are around 5cm dilated. At 1 finger, you are fully dilated. (Awesome, huh!)

Understanding the bottom line. There is something called the “bottom line,” which is a shadow that extends from the anus up towards the back along the crease of the buttocks. It begins as 1cm and lengthens to 10cm, and it’s length correlates with cervical dilation. Why not look down there before inviting a stranger to put their fingers up inside you? It makes sense to me.

Hope these tips and signposts of labor help you and your partner have a confident, good birth!

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