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How Do You Know When It's Time To Go (Or Call Your Midwife)?

Whether you're giving birth for the first time or the fifth, sixth, and so on, discovering that labor has started releases a myriad of thoughts and emotions. For some moms, there may be a degree of uncertainty about whether they actually are in labor. In first pregnancies, it can be hard to discern because there is no previous labor experience with which to compare, and in subsequent pregnancies, labor may feel completely different than previous experiences, making it hard to determine whether the process has actually begun. One of the biggest questions surrounding the onset of labor is when to leave for the hospital or birth center, or if birthing at home, when to call the provider. Long story short, there is no hard-and-fast rule for deciding when to call or when to leave, but there are guidelines and recommendations that can help mothers and support persons decide when the time is right.

What's the 4-1-1? One method for recognizing when labor may be transitioning (or has already transitioned) from early labor to active labor is 4-1-1. This means that contractions are four minutes apart, lasting at least one minute, and that this pattern has continued consistently for at least one hour. Not all providers and resources use 4-1-1, however; some use 3-1-1 (contractions are three minutes apart, not as common) and some use 5-1-1 (contractions are five minutes apart). The variability in this guideline can understandably cause confusion and lead to anxiety, stress, and potentially leaving for the birth location either too early or too late.

But how do you know which numbers to use? Some of that depends on whether the current pregnancy is a first pregnancy or a subsequent pregnancy. Early labor on average lasts anywhere from six to twelve hours, with this stage typically being longer in first-time mothers than those who have given birth before. In this case, it may be more appropriate to use 4-1-1 or even 3-1-1 (although proximity to the birth location or the decision to birth at home would have some bearing on waiting until contractions are three minutes apart). Women giving birth for the second, third, etc. time or those who have experienced a precipitous birth (birth occurring approximately three hours or less after the establishment of a regular contraction pattern) may want to use the 5-1-1 guideline as their labors are typically shorter than that of a first-time mother.

As I mentioned above, distance from the birthing location also should come into consideration. In Wyoming, where I currently provide doula services, people and services are very widespread, and it isn't uncommon for patients to drive sixty miles or more to reach a hospital, doctor's office, or other healthcare facility. Birthing centers and homebirth midwives are available, but scattered across the state, so a mother who wants to utilize these services may find herself traveling even further to do so, even possibly out of state if this is where the closest facility is located. Knowing the distance between home and the chosen birth location or home birth provider will help to determine if more travel time is needed.

Contraction Timing: Treat the Person, Not the Clock! After reading the guidelines above, it can be tempting to fall into the perceived safety net of timing every, single contraction. But doing this doesn't really yield much useful information and it takes the attention off of the one person who can demonstrate when labor is changing and progressing: the mother. When working as a nurse, we were always reminded to treat the patient first, not the monitor. With continuing advancements in technology and a never-ending onslaught of new equipment, it was easy to substitute the data the machines were displaying for the actual patient. A cardiac monitor may suddenly show a rapid, erratic heart rate and rhythm, causing staff to race into a room only to find the patient's grandchild vigorously shaking the monitor cords while the patient rests quietly in bed. If we were to ignore the patient entirely and respond only to the monitor, we would initiate unnecessary and potentially harmful resuscitative measures on a person who does not need them.

The same can be said for timing contractions and using this information alone to determine when to leave or call the birth team. In the case of a hospital birth, this could result in arriving too early in labor and being sent home, or being encouraged to consent to admission and induction methods to "encourage labor progress," setting up a situation ripe for the Cascade of Interventions ( ). In the opposite scenario, timing contractions without observing the mother's behavior could result in leaving too late and giving birth in the car, or at home unassisted when this wasn't the original plan.

The best way to time contractions is in short segments when the situation warrants it. When the mother first notices contractions, time five to ten in a row to establish a baseline. Then try to distract her from the fact that she is in labor. As I noted above, early labor can last several hours and it is best to navigate this stage at home where she feels safe, sheltered, and is in a familiar place. Early labor is for resting, napping, eating and drinking, and taking occasional walks if she is too anxious or excited to sleep. Conversely, active labor requires energy to do just that - get active: change positions, walk, sway, squat, etc. - so early labor requires mom to build stores of that energy for the hard work ahead.

If at any time, you notice a change in the mother's affect or behavior, this is a good indication that cervical change is being made and contraction timing should be resumed. Active labor is likely approaching or has arrived is if the mother cannot continue to walk and talk through contractions as she had been previously. If she needs to stop during a contraction, lean on furniture or a support person, and breathe rather than talk, she is likely moving toward active labor. At this point, contractions that are determined to be three-to-five minutes apart and are accompanied by a mood and/or behavior change are good indicators that it may be time to leave or call the provider.

The start of labor can be exciting, stressful, even scary, and knowing when it's the right time to leave or call in the homebirth provider can feel confusing and overwhelming. If there is ever any question, calling the midwife, physician, or doula is encouraged and can be very helpful. Once they receive information about the situation thus far, they will likely ask to speak to the mother, using the sound of her voice, her breathing pattern, any sounds she is making to help gauge where she is in her labor progress. Some providers may encourage leaving for the hospital sooner so they can more closely monitor (and likely manage) labor. This is why it is so important for mothers and their support people to become educated on the signs of labor progress if they want to remain at home as long as possible.

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