My couples are so concerned about when they’re supposed to go to the hospital. As a Childbirth Educator, you have to cover this information early on in the class or they freak out.
It’s good to remember this generation of birthing people 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 pregnant person stands up in a very embarrassing and public space, announces loudly that their water has broken and then find themselves in gut-wrenching pain. They’re then rushed off to the hospital at break-neck speed, and their 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 laboring people 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But since we’ve discovered that Friedman’s Curve for labor is obsolete (read much, much more about that here) and we know that it takes people today much longer to labor and deliver their babies, there’s a new phrase bandied about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For my first 15 years of teaching, we were basing our 5-1-1 instruction on outdated information!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-timers, 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 medicalized too quickly.
We should also help them set realistic expectations about what happens when “go time” finally arrives. I often ask my students to do a little math when we’re talking about this time of labor. “How many contractions do you think you’ll have trying to make your way from the living room to the car parked in the driveway, if your contractions are coming at 5 minutes apart?” Most people answer, “1 or 2?” Sometimes I get, “Zero.” This makes sense if they’re just hanging out, but I have to remind them if they are actually having contractions at 5 minutes apart, they’ve been lasting for a minute each and they’ve been in this pattern for at least an hour, they’re not just hanging out – they’re in labor. It’s unlikely that they’ll jump up off the couch at the end of a contraction, grab the bag from you and skip down the steps.
Most people in labor at this point will not be walking, talking or smiling at the peak of the contractions. They will be moving s-l-o-w-l-y. And they just might turn into a hot, weepy dependent mess. Why? Because it’s Go Time! This is not “false labor” and now, they have to actually push the baby out! Expect them 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 they has to sit strapped into that bucket seat will be agony!
A person 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 families need to know that if they have a contraction pattern of 5-1-1, that we’re keeping our fingers crossed that they will have gotten to 3 cm when initially checked for dilation.
Consider for a moment, what happens to the laboring person who’s convinced that they’re “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 families: The “Drive-to-the-Hospital-3” is a lying, cheating, deceitful 3! And if you were still in your living room, you’d move through 4, or 5cm 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’d never willingly agree to unless heavy medication is 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!
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 person hears that they are 3 out of 10 cm along, that means they’re only 30% of the way done. But if they’re 13 out of 20 cm along, then they’re closer to 65% of the way done – and this is much more reflective of labor math. I’m all for whatever can help a person’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 some 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 your contractions are longer, stronger and closer together, your focus is entirely on the contractions, and at the peak of each contraction you’re 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?