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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 stages, the diagnosis of which relies on clinical assessments of contraction pattern and cervical dilatation. Although research does not support the notion that such clinical assessments can determine the future progress of labour, they underpin maternity care.

What research does show is that concepts of stages of labour do not align with women's perception and assessment of their own birth process [1; 2]. When it comes to the experience of early labour, women's experiences are diverse and do not necessarily fit the clinical 'symptoms' used to define it [3; 4].

In addition, 'early' is only 'early' with hindsight. At one point in time (ie 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? An individual woman's body is unique and so is her labour pattern.

Physiology of Early Labour

There is also a general disregard for, and misunderstanding of the physiological importance of 'early' labour.

Like all other mammals, labouring women seek a private and safe place to avoid distraction and immerse themselves in the act of birthing. During early labour a woman seeks a place to settle and 'nest'. Her neocortex is still engaged and can slow contractions (by reducing oxytocin) in response to thinking, talking, etc. This helps her to think clearly and do the practical things involved in a physical move. The release of adrenaline due to excitement and stress also helps to keep the woman alert. Increased oxytocin re-establishes contractions once the woman is settled (and adrenaline reduces) and her neocortex is not being stimulated. This explains why labour often slows down in response to the move to hospital. However, as labour progresses (into liminal phase) 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 woman who arrives at the 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, and doulas.

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 [5; 6]. There are two explanations for this:

1. That these women already have a dysfunctional, prolonged labour, which is why they are coming to the hospital in early labour.
2. That exposure to the routine interventions involved with care in a hospital setting increases the chance of complications occurring [7], ie, the longer the woman is in the system, the more opportunity there is to 'do stuff' to her and mess things up.

Women admitted to hospital in early labour also cost the institution more money because they are on the ward for longer, which increases the demand 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 the hospital to enquire about coming in, they are often advised to "take paracetamol, have a bath, then ring back in an hour". Women are also told to only come to the 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 (virtual support/home visits) have been devised to support women to stay home during early labour 8; 9]. When women arrive at the hospital, they are subjected to invasive clinical assessments to diagnose 'established labour' before they are cleared for admission to the labour ward. In my book I refer to this practice as checking credentials and gatekeeping the birth space.

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', or 'niggling', or that '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 a judgement on hospital midwives. I've been there myself, and it is very frustrating dealing with a woman in early labour whilst also caring for one or more women in advanced labour. Whilst I am not condoning the hospital perspective on early labour, I can understand it from a cost/staffing perspective. Maternity systems are set up around the needs of the institution rather than individual women.

A study by Shallow et al. summed up the situation [10]: "...current maternity services appear constrained by a reduced midwifery workforce that is expected to meet excessive organisational demands whilst coping with reduced bed capacity. These pressures can promote changes in midwives’ behaviour and thinking which disconnects them from mothers rather than focusing on their needs. Safety depends on a high degree of midwife to mother continuity. However, a business model approach, prioritising throughput and process promotes fragmented care and can potentially threaten the safety of mothers and babies."

Women's Perspective: seeking reassurance and safety

Findings from qualitative studies suggest that staying away from the hospital during early labour can be challenging for women. It seems that women want to be in a hospital. And the experience of being assessed as ‘not in labour’ and sent home can be distressing and result in women feeling unsupported [11; 12]. A study of first-time mothers found that women experienced embarrassment when they arrived at the hospital too early to stay [13]. They also felt vulnerable when negotiating with midwives to stay. An Australian study into women's experiences of early labour care identified three descriptive themes: needing permission, doing the 'wrong' thing, and being dismissed [11].

Safety

The need to be in a hospital is not necessarily about needing pain relief or support. One study found that women wanted to be in the 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 [14]. Another study found that women were concerned for the wellbeing of themselves and their baby whilst labouring at home and identified the theme ‘handing over responsibility’ as the core category emerging from the data [15]. Women were keen to transfer to the hospital to hand over the responsibility for safety to midwives.

Assessment of labour progress

Another concern associated with staying at home during early labour is uncertainty about identifying when established labour begins. Research has found that women struggle to identify the onset of active labour [16] and are concerned about not knowing how advanced their labour was [15]. Women worry about going to the hospital too soon or too late, and are unsure of how to know if their labour is ‘the real thing’ [16]. Their main concern about staying at home was not being able to have their labour assessed by hospital staff.

Once women arrive at the hospital in early labour, they are subjected to clinical assessment aimed at assessing labour progress. Despite these assessments being inaccurate, the midwife's assessment was considered authoritative. In one study, women perceived midwives as ‘gatekeepers’ with whom they had to negotiate their credibility to gain access to the hospital [13]. Women's own assessment of how and when their labour began often does not match the midwife's clinical assessment of labour onset [17]. A study of first time mothers found that women were perceived as abnormal by hospital staff if their experience of labour onset did not fit clinical definitions [18]. Themes identified from the data included this is not right, and don’t trust your body, trust us. One of the outcomes associated with the confusing and contradictory messages given to women about early labour is women giving birth before getting to hospital [10].

Physiology and Contradictory Messages

As we have seen above, early labour is a woman's signal to get settled somewhere safe and to gather her support people around her.

What is considered a safe place is influenced by the culture in which the birth is taking place. Women in Australia (and many other parts of the world) are urged to birth in hospital because cultural concepts of safety involve medicine and technology. The experts in birth are the people who know how to use the medicine and technology, and can carry out clinical assessments to determine wellness and progress. 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 home + well known women-folk with hospital + unknown medical staff.

The emphasis on the hospital as a place of safety whilst also encouraging women to stay away results in some very contradictory messages and ideas:

• We are the experts on your labour progress; only our clinical assessments can determine what is happening. But we'd rather you not come in to be assessed and instead stay at home without knowing what is happening.
• 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 on your labour and our clinical assessments can predict your future labour progress. But we will send you home if you are found to be in early labour, and 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 woman who labours at home and comes into hospital 'fully and pushing' is praised, "she did a great job". Yet she laboured (perhaps for many hours) without the attendance of a professional and any monitoring (eg, fetal heart rate auscultation). On the other hand, a woman who homebirths intentionally is considered to be doing something unsafe despite the constant attendance and monitoring of a 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. Here are some thoughts, as usual I'm ignoring constraints of the system and money in favour of idealism:

• Antenatal care should build self-trust and reinforce the woman's expertise in birthing her baby. If she relies on herself to determine wellbeing and progress, she may be less likely to head to the hospital early for reassurance. A study of first-time mothers found that those who remained at home during early labour expressed a sense of power [15]. Maintaining power was the central focus for these women, and it involved a sense of authority over their bodies.
• Give early labour respect. It is an integral part of the birth process, and women deserve recognition for it. Don't use the terms 'latent' or 'not in 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 criteria which involve invasive clinical assessments. They should be able to use early labour to get to their safe place and settle for birth.

• Providing woman-centred early labour care in an out of home setting is possible [19].

  Of course, if a woman is birthing at home with a known and trusted midwife, it is a different kettle of fish. She doesn't need to concern herself with 'when to go to hospital', and her midwife 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. To turn this around is a huge undertaking, and change will undoubtedly meet resistance from those who benefit from the way things are.

Further Resources

I cover the physiology of early labour in my Childbirth Physiology Course and explore physiology, research and practice in my Reclaiming Childbirth Collective.

Related blog posts

• Vagina Examinations: stuck on the cervix
• Understanding and Assessing Labour Progress
• The Assessment of Progress

Related podcast episodes

References

1. Dixon et al. (2013) Women's perspectives of the stages and phases of labour
2. Reed et al. (2016) Women's experience of birth: childbirth as a rite of passage
3. Grylka-Baeschlin & Mueller (2023) Symptoms of onset of labour and early labour
4. Stone & Downe (2023) Women's experience of early labour in a free-standing birth centre
5. Miller et al. (2020) Variations in outcomes for women admitted to hospital in early versus active labour
6. Rota et al. (2018) Timing of hospital admission in labour
7. Bailit et al. (2009) Outcomes of women presenting in active versus latent phase of spontaneous labor
8. Borrelli (2023) How should a video-call service for early labour be provided?
9. Janssen et al. (2009) Roundtable discussion: early labour: what is the problem?
10. Shallow et al. (2018) Exploring midwives' interactions with mothers when labour begins
11. Allen et al. (2020) Women's unmet needs in early labour
12. Scotland et al. (2010) Women's preferences for aspects of labor management
13. Eri et al. (2010) Negotiating credibility
14. Cheyne et al. (2007) 'Should I come in now': a study of women's early labour experiences
15. Carlsson et al. (2012) Maintaining power: Women's experiences from labour onset before admittance to maternity ward
16. Beebe et al. (2006) Expectations, perceptions, and management of labor in nulliparas prior to hospitalization
17. Gross et al. (2009) Onset of labour: women's experiences and midwives' assessments in relation to first stage duration
18. Low & Moffat (2006) Every labor is unique but "call when your contractions are 3 minutes apart"
19. Stone & Downe (2023) Women's experience of early labour in a free-standing birth centre