Labour guide: when to go to hospital and what to bear in mind

After around 9 months of pregnancy, a much-anticipated day approaches: labour. And just like pregnancy, every labour is different and doesn't have to be anything like earlier ones, or those of your family and friends. It's an important moment that raises plenty of questions. That's why we, the midwives at Happymami, have written this special post for you: the labour guide, when to go to hospital.

Signs and symptoms of labour: when to go to hospital and what to do

Around two weeks before your estimated due date, a series of warning signs and symptoms will appear. This stage is known as prodromal labour, and how long it lasts and how intense it is can vary from one pregnant woman to another.

Prodromal signs and symptoms of labour

To begin with, your baby may move down into the birth canal, so your bump drops. Thanks to this, digestion feels lighter and heartburn eases if you had any. However, your bladder will be under more pressure, so you'll need to wee more often and in smaller amounts. As your baby drops, their head engages in the pelvis and your baby's movements may slow down. You may notice more backache and other general symptoms such as wind, restlessness and unease, headaches and vomiting.

If you haven't had any contractions yet, they will start, especially in the afternoon and at night. They feel like muscle contractions or a stabbing pain low down in your abdomen. They aren't rhythmic and usually stop or ease with rest. Unlike labour contractions, these contractions don't cause any dilatation, but they do get the cervix ready for labour by softening it. As the cervix softens, you may lose your mucus plug. You'll recognise it because it is usually thick and more or less dark, or even blood-tinged, but it's all perfectly normal.

At this stage your waters may break, even without contractions. This rupture of the membranes isn't, in principle, any risk to your baby, as long as the pregnancy is full term. It can, however, be an infection risk for the mother. So if this happens, go to your hospital. Bear in mind that you'll be asked some important details: the time your waters broke, how much fluid you lost and what colour it was. They will then decide on the best treatment for your situation.

What should you take to hospital for the birth?

In Spain, all the public centres you go to usually have everything needed for mum and baby during your stay in hospital. But since every case is different, we all have different needs and it can vary from one centre to another, it wouldn't hurt to take a bag of toiletries for you and your baby. And if you go to a private centre, you'll need to take these things with you, both clothes and toiletries.

The contents of this bag will be personal, and you should prepare it well before your due date, because when the time comes to go to hospital, that won't be the best moment to pack it. In any case, don't wear any kind of jewellery, piercings or nail varnish.

Bag for mum

A bag with toiletries, disposable knickers, slippers, a dressing gown and a couple of nightdresses (opening at the front so breastfeeding is more comfortable).

Bag for baby

• Clothing may differ depending on the time of year you give birth. It's best to use clothes without ribbons, buttons and zips; velcro clothes are easier to put on and take off.
• Bodysuits, pyjamas, socks or booties.
• Newborn-size nappies, baby wipes.
• A shawl, wrap or blanket for leaving hospital.
• Baby seat or pram.
• A child car seat suitable for a newborn: groups 0 and 0+.

When should you go to hospital in labour?

Deciding the moment to go to hospital can be quite a challenge. The most important thing is to stay calm and not rush.

If this isn't your first baby, and especially if your previous labours were quick, you should go to hospital at the first sign of discomfort, which you'll recognise from your previous experience. Your bump will tighten evenly, for around a minute, and at intervals.

If this is your first baby, everything usually takes a little longer. The early phase, the prodromal stage, tends to last longer, and if you go to hospital too soon it can become tedious. There's nothing like being at home, alternating comfortable positions, having a warm bath (if your waters haven't broken), etc., as long as you're not too far from the hospital.

Labour starts spontaneously when contractions are rhythmic (they don't ease with rest and gradually increase in intensity, duration and frequency), every 5 minutes, for one full hour.

Other reasons to go to hospital even if rhythmic contractions haven't started yet.

• Your waters breaking, even if there are no contractions; bear in mind that rupture of the membranes sometimes causes doubt because a large amount of fluid doesn't flow out, and occasionally what we call a high rupture or a slow leak can happen, with the fluid coming out very slowly and in small amounts.
  • To check whether this is the case and not heavy discharge or urine leaks (amniotic fluid has no smell), put on a sanitary pad and check that it gradually becomes damp and that the loss increases with movement or coughing. If the colour isn't clear, go as soon as possible, although not as an emergency, to rule out any complication.
• Bleeding that is heavier than a period. (It shouldn't be confused with light spotting, which is normal after a vaginal examination, nor with passing the mucus plug, which, as we mentioned earlier, may be blood-stained mucus).
• A sudden drop in, or absence of, your baby's movements. It's well known that your baby's movements gradually decrease from around week 32 until the end of pregnancy; this reduction in your baby's movements is explained by the fact that the amniotic fluid they move in also decreases and the space your baby “lives” in gets smaller as they grow. Even so, it's a warning sign to suddenly feel very few, weak movements or none at all.

What are contractions like?

Contractions can be more or less painful. Although in general, pain is a factor that tends to accompany contractions: at first it's a discomfort in the abdomen that can radiate to the lower back, and as dilatation progresses it becomes more intense and severe, radiating through the whole lower back and the sacrum. Every woman feels the contraction differently. That said, it's essential to have a calm, relaxed and cooperative attitude, which will help you keep your uterus more relaxed and favourable to dilatation too. You'll also tire less and breathe better, which means your baby will also get better oxygen, something that is very important for them at these moments.

What happens when you arrive at hospital?

When a pregnant woman arrives at hospital, depending on the hospital's protocol, you'll be received by the midwife or the gynaecologist, and after an assessment they'll decide whether or not you are in labour. To assess whether you're in labour, the midwife or gynaecologist will carry out a vaginal examination, checking your dilatation and the state of your cervix, how high your baby is in the pelvis, and even whether the amniotic sac is intact. They will also perform a cardiotocograph to check your baby's heart rate and your contractions, their frequency and intensity. This is an overall assessment of the situation, after which they'll decide whether to admit you or send you back home. As a guide, admission to hospital is recommended when the following criteria are met: regular uterine activity, cervical effacement > 50% and dilatation of 3-4 cm.

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Stages of labour

Once labour has started after the prodromal stage, it is divided into 3 periods or stages: dilatation stage, expulsion stage and placental delivery stage.

First stage of labour: dilatation, definition and timings

This stage is in turn divided into the latent phase and the active phase. The latent phase begins with the start of labour and is characterised by contractions that vary in intensity and duration, and is accompanied by effacement of the cervix and a slow progression of dilatation up to 2 or 4 cm. The active phase is characterised by increasing regularity, intensity and frequency of contractions and a rapid progression of dilatation.

Traditionally, the length of dilatation was considered a very important and compromising factor for the health of mums and their babies. But the length of labour varies from woman to woman, is influenced by the number of previous births and doesn't have to progress in a linear way.

It isn't possible to establish the length of the latent phase of dilatation because it's difficult to determine the start of labour. But it is for the active phase of labour, which varies from one woman to another.

• Primiparous women (first pregnancy)
  • The average length is 8 hours.
  • It's unlikely to last more than 18 hours.
• Multiparous women
  • The average length is 5 hours.
  • It's unlikely to last more than 12 hours.

In this phase contractions are usually rhythmic, every 2-3 minutes. When spontaneous contractions aren't rhythmic, an oxytocin drip is usually started, as it's essential for the woman to have regular contractions to help labour progress.

What to do during the dilatation stage of labour

Now the time has come to put everything you learnt in your antenatal classes into practice. Practising relaxation and breathing techniques will be very useful, and if you need it, your midwife is there for you and will be delighted to advise you on the positions that suit your case best and help labour progress.

Some hospitals currently ban eating solids and drinking liquids during this stage and until the end of labour. This ban is based on the possibility that an intervention under general anaesthetic might be needed. It's a procedure that has become obsolete if applied without exceptions. But it depends on the protocols set by each hospital's anaesthesia and resuscitation department. If you just want to refresh your mouth and dry lips, you can ask for a gauze soaked in water, rinse your mouth and brush your teeth. For lips that tend to be cracked, you can use vaseline.

If you can drink liquids, or even eat, do so depending on how far along in labour you are and always after talking to the midwife caring for you, and if it's covered by the unit's protocols. The recommendation is to drink clear liquids (water, juice without pulp, tea or coffee, isotonic drinks). Isotonic drinks are the most recommended because, as well as hydrating, they provide small amounts of glucose and prevent ketosis. Empty your bladder, ideally spontaneously (while you don't have an epidural). If circumstances allow (no restriction of movement), you can go to the toilet by yourself, helped by your partner or the midwife accompanying you at that moment.

As far as possible, meet your expectations for pain relief during labour; talk to your midwife about the options available. Also remember that you don't routinely need an enema or to be shaved.

You don't have to stay lying down. If you want to, and the epidural doesn't reduce the mobility of your legs, you can ask to stay sitting up, on the ball, standing or walking around, although the midwife is the one who will assess the specific circumstances of each moment and each woman. The aim is to be as comfortable as possible while dilatation progresses well and nothing affects your baby's safety.

Second stage of labour: expulsion, timings and what to do

The second stage of labour or expulsion stage is the time between reaching full dilatation and the moment your baby is born. It is in turn divided into two phases:

• Passive phase of expulsion
  • Full dilatation of the cervix before, or in the absence of, involuntary contractions in the second stage (an urge to push).
  • The uterine contractions move your baby's head down through the vagina.
  • The normal duration for women who haven't given birth before is up to 2 hours, whether or not they have epidural analgesia.
  • The normal duration for women who have given birth before is up to 1 hour without epidural analgesia and 2 hours with it.
• The active phase of expulsion (when any of the following applies)
  • There are expulsion contractions with full dilatation
  • Your baby is visible
  • Maternal pushing with full dilatation and no expulsion contractions
  • The normal duration for first-time mothers is up to 1 hour without an epidural and up to 2 hours with one.
  • The normal duration for women who have given birth before is up to 1 hour, whether or not they have an epidural.

What to do during the expulsion stage of labour

If you don't have an epidural, or if its effect and the situation allow it, get into the position you find most comfortable, avoiding lying on your back. Upright positions (sitting, standing, squatting) or side-lying positions are linked to shorter expulsion phases. Women who adopt a hands-and-knees position find it the most comfortable for giving birth, and have reported less back pain and less perineal pain after birth. Also, warm compresses should be applied to the perineum during the expulsion stage, and perineal massage avoided during the second stage of labour.

During this stage, pain may increase because of the stretching of the perineum. You'll feel a strong urge to push caused by pressure on the pelvic nerves, and you'll probably feel relief with each push. If you have epidural analgesia, this period usually lasts longer: you won't feel pain, but you'll be aware of a feeling of heaviness or pressure in the perineal area. It's very important to follow all the instructions you're given (breathing in, pushing, breathing out, relaxing, the right position, etc.), which are always aimed at the best possible outcome for you and your baby.

An episiotomy should not be performed routinely during a vaginal birth, even in women who had third- or fourth-degree tears in previous births, and should only be carried out if there is a clinical need, such as an instrumental birth.

Your baby's birth

After your baby is born, the umbilical cord will be clamped, preferably after two minutes or when the pulsation stops. Your baby will be placed in your arms so you can hold them skin to skin on your bare chest. It's important that healthy babies stay skin to skin with their mother immediately and uninterrupted from the moment of birth for one to two hours. And that, if the mother wishes, breastfeeding starts as soon as possible.

So separation of mother and baby will be avoided, at least during the first hour, until the first feed has finished. If possible, this contact should be maintained for as long as the mother and baby need it. Postponing routine postnatal care of the baby, such as weighing, giving eye ointment, vitamin K, hepatitis vaccine, etc.

Third stage of labour: delivery of the placenta

The third stage of labour is the time between birth and the expulsion of the placenta. Its duration is considered prolonged if it isn't complete within 30 minutes of the baby's birth with active management (giving oxytocin after the baby is born) and 60 minutes with spontaneous delivery of the placenta. This active management of the third stage of labour is carried out because it shortens its duration. It reduces the risk of postpartum haemorrhage and the need for therapeutic oxytocin. But spontaneous or physiological delivery of the placenta is an option if the woman requests it. In this phase, your cooperation with pushing or relaxing is also needed, which your midwife will guide you through as appropriate so that the placenta is expelled.

What to do about the pain of labour?

In a normal birth that isn't induced with oxytocin, with no restriction of movement and in a supportive environment where the mother feels safe and comfortable, many women can cope with the pain, thanks to the gaps between contractions that allow them to rest and the painkillers released by the body. Nowadays you'll be able to access the different non-pharmacological and pharmacological methods available for pain relief. You can choose one method or several and switch between them depending on how labour progresses and how much relief you want at each moment. To make an informed decision about these methods, it's worth knowing the pros and cons of each one:

Non-pharmacological methods

• Immersion in warm water moderately reduces pain, helps relaxation and reduces the use of epidural analgesia as long as it is done during the active phase of the first stage of labour (≥4cm dilatation), without any adverse effects on the length of labour, the caesarean rate or your baby's wellbeing.
• Massage and calming physical contact from your birth partner relieve pain and anxiety during dilatation and the expulsion stage, with no unwanted effects.
• Using birthing balls can make it easier to get into comfortable positions.
• Relaxation techniques and breathing techniques can be helpful and don't produce unwanted effects.
• Sterile water injections are useful for the relief of back pain that some women
  experience during contractions, but they cause stinging and intense momentary pain.

Pharmacological methods

• Inhaling nitrous oxide provides moderate pain relief that many women find sufficient. However, it can cause nausea, vomiting and slight dizziness, which disappear as soon as the inhalation stops.
• Intravenous and intramuscular opioids have a limited analgesic effect and can cause nausea and vomiting. By making your baby sleepy, they could cause respiratory depression and interfere with breastfeeding.
• Epidural analgesia is an invasive technique, which is why the woman must be informed about its benefits, risks and implications for labour:

Epidural analgesia

It's a very widely used treatment for pain in different medical procedures, but especially for labour. It won't be given until you've been examined and it's confirmed that, in principle, there is no contraindication to using it. Remember that it's important to have signed the appropriate consent form before being admitted to hospital.

Benefits of epidural analgesia

• It is the method that provides the most effective pain relief.
• Epidural analgesia at low doses allows you to walk around.

Risks of epidural analgesia

• Maternal hypotension and the resulting loss of foetal wellbeing, which is treated with intravenous fluids and vasoactive drugs.
• Intrapartum fever, which creates diagnostic problems with other causes of fever and may mean the mother and baby have to undergo tests.
• Difficulty passing urine and urinary retention, which must be treated with repeated bladder catheterisation.
• Restricted mobility, being unable or finding it difficult to walk around, legs feeling numb or not feeling them at all.
• It is associated with a longer expulsion stage and a higher risk of needing help for the birth with forceps, ventouse or spatulas.
• On the other hand, epidural analgesia is not associated with longer dilatation or higher caesarean rates. Nor is it associated with long-term back pain.

Contraindications for an epidural

• Tattoos covering the puncture site.
• Clotting disorders and treatment with anticoagulants.
• Local infection (at the puncture site) or general infection.
• Eclampsia.
• Severe haemorrhage or shock.
• Labour very advanced or the appearance of complications requiring it to be brought to a rapid end.
  • With very advanced dilatation (8-9 centimetres) it isn't indicated, as the possibility of complications outweighs the potential benefits, and its effectiveness is also very low in these circumstances.

Caring for your baby after birth.

After birth, babies are in a very special state: they are awake, alert to what is going on around them, with their eyes open, a very sharp sense of smell and active reflexes. It's worth knowing how important this moment is, and it lasts barely two hours, so you can make the most of it. That first contact, in which baby and mother look at each other, touch and smell each other, is an unforgettable experience.

You and your baby will stay skin to skin, cared for by the midwife, who will check your general condition, your vital signs (blood pressure, pulse and temperature) and the maintenance of adequate uterine contraction, monitoring how your newborn adapts.

Skin-to-skin contact helps babies adapt to life outside the womb and keep their temperature. It also reduces crying time, (why is your baby crying?), strengthens the bond between mother and baby, is very pleasant for both and makes it easier to establish breastfeeding, since your baby instinctively seeks and finds the nipple, latches on spontaneously and starts the first feed. This spontaneous latching on after birth is linked to easier breastfeeding that lasts longer. Breastfeeding guide: the first days.

The midwife will help you with the first feed if you want to breastfeed. If in your case you don't want to breastfeed your baby, you shouldn't miss out on the other benefits of skin-to-skin contact, which will be done in the same way. If you prefer, you can avoid the baby reaching the nipple and sucking, or allow this first suck without continuing with further feeds afterwards.

Conclusion: labour guide, when to go to hospital

Once labour has taken place, a new stage begins that you and your partner will have to adapt to. Every case is different, and it always involves continuous learning for this new stage. But above all, we'd remind you that in Spain we have professionals who are admired internationally: trust your midwife and gynaecologist, because they want what's best for you and your baby. And congratulations in advance! We hope this post with the labour guide, when to go to hospital has helped you. We also leave you here the latest update on maternity and paternity leave.

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