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Commencement Of Labour

Commencement Of Labour
What are the signs for the onset of real labour?

At first, you may feel Braxton-Hicks contractions. When real labour begins, these contractions get considerably intense. As their frequency increases, they become more painful and can not be relieved by a change in position. The pain first begins in the lower back and then spreads to the lower abdomen and legs. This may be accompanied by diarrhoea. Contractions are now taking place at regular intervals, and should be timed. You may also have a pinkish or blood streaked discharge from the vagina. In 15% of cases, it has been seen that the water bag breaks (also known as rupturing of membranes) before labour begins. When this happens, water (actually amniotic fluid) may either gush out or just trickle. If you begin experiencing these symptoms, call your doctor and rush to the hospital.

What are Braxton-Hicks contractions?

This is a method by which the pregnant uterus does a practice run prior to actual labour. The uterus is warming up in preparation for the grand finale - the arrival of your baby. They begin around the 20th week of pregnancy. You will feel a tightening of your uterus that is usually painless, but can be uncomfortable. The contraction begins at the top and slowly spreads downwards. They can last from 30 seconds to over 2 minutes. As you come closer to the time of delivery, these contractions may become more frequent and intense, bordering on painful. You may even mistake them for actual labour contractions. Braxton-Hicks contractions can trigger early effacement (thinning of cervix) and dilatation.

How to deal with Braxton-Hicks contractions?

As your due date draws nearer, your Braxton-Hicks contractions will become more intense, painful and frequent. Lying down and relaxing or walking around can help relieve the discomfort of these contractions. Changing your position may stop the contractions completely.

What is a "bloody show"?

Another sign of the commencement of labour is that your vaginal discharge will thicken and increase and you might find a blob of mucous escape from your cervix (looking like pink vaginal discharge). As the cervix begins to thin and open, the mucous plug that seals the opening of the uterus, slides out through the vagina, a couple of weeks before the onset of labour. You may notice a blood-tinged mucous discharge known as "bloody show."

Does a "bloody show" indicate commencement of labour? This just indicates that your cervix is effacing and dilating in preparation for the onset of labour, which could still be two or three weeks away. In subsequent pregnancies, this happens just as labour begins. If this is followed by contractions, then do not hesitate to go to the hospital, because it could indicate the commencement of labour. On the other hand, if your discharge becomes bright red or you just start bleeding even a little, contact your doctor at once, as it could be an indication of premature separation of the placenta (placenta praevia), and requires prompt attention.
Leaking urine or have the membranes ruptured? Just smell the wet spot on your underwear. If it smells sweet, it must be amniotic fluid. This stops once you stand up, as the baby's head moves into position and acts like a stop cork. However, if the spot smells like ammonia, you have most probably urinated. A constant trickle or a sudden gush from the vagina usually indicates that "your waters have broken" or that your membranes have spontaneously ruptured. By "waters", one means the amniotic fluid surrounding the foetus during pregnancy. This is a sign that labour should commence within the next twenty four hours.
What if membranes rupture in public? This is highly unlikely as in 75% cases, membranes are known to rupture only after labour progresses. And once the water breaks, the flow is only heavy if you are in a sleeping position. So even if it does occur, you are hardly likely to be lying down in public. When you are standing or walking, a little amniotic fluid might trickle out at the most, because the foetal head blocks the opening of the uterus. And since contractions haven't yet started, there is no force trying to push the fluid out. If you are still worried about rupturing your membranes ruptured in public, wear a panty-liner for the last couple of weeks.
The first contractions normally start within 12-24 hours after the water breaks. However, in 1 out of 10 cases, labour has to be induced, because once the membranes have ruptured, the risk of infection to the mother and child increases. So you must report this to your doctor, and in the meantime, keep the vaginal area clean and use a sanitary towel (not a tampon). Don't have a bath or indulge in sexual intercourse. And of course, resist from carrying out your own internal examination. However, if you think you can feel something in your vagina, make sure that you get immediate medical attention, as it could be a prolapsed umbilical cord.

Some people say diarrhoea indicates commencement of labour. This is true. Just before the onset of labour, some women experience loose motions. So if you have diarrhoea, get your hospital kit ready, because it could indicate commencement of labour.

Premature Labour and False labour

Are you already getting small contractions? Could it indicate premature labour? If it is accompanied by pain, a vaginal discharge and you are getting more than four in an hour, you could be in for premature labour. If not, then these are Braxton-Hicks contractions. Your uterus is having a sort of a practice session for the real thing. This normally starts from the 10th week and could last anywhere between 30 seconds and 2 minutes. In the 9th month, these contractions become more frequent and intense and could even be mistaken for the beginning of real labour. You must try to lie down and relax or get up and walk around.

If you are having erratic contractions that do not increase in frequency or severity, then real labour has not yet begun. If you were to walk around or change your position, these contractions will subside. In false labour, pain is felt in the lower abdomen rather than the lower back and the show, if any, will be brownish rather than pink or bloody. (Brownish discharge could even be the result of an internal examination or intercourse). If foetal movements intensify with each contraction, it could indicate foetal distress. So call your doctor now.

Situations requiring Immediate Medical Attention

Greenish-brown discharge from vagina

This is a substance called meconium and it comes from the baby's digestive system. It is usually passed as the baby's first stool. As it could be suggestive of foetal distress, it warrants immediate medical attention. Generally this happens if the baby is post mature. Meconium just passes into the amniotic fluid before delivery.

Membranes have ruptured and there feels something in vagina

Once the membranes have ruptured, the risk of infection to the mother and child increases. So you must report this to your doctor, and in the meantime, keep the vaginal area clean and use a sanitary towel (not a tampon). However, if you think you can feel something in your vagina, make sure that you get immediate medical attention, as it could be a prolapsed umbilical cord.

Is a "bloody show" the same as bleeding

No. If you have had a "bloody show" and your discharge becomes bright red (instead of pink) or you just start bleeding even a little, contact your doctor at once. This could be an indication of premature separation of the placenta (placenta praevia), and requires prompt attention.

Foetal movements seem to be intensifying with each "false" contraction

Even though all the signs point towards a false labour, if foetal movements intensify with each contraction, it could indicate foetal distress, requiring immediate medical attention.

Things to consider in the early 1st phase of Labour

The early 1st phase is viewed as the time when the woman's labour changes from being in prelabour, and moves into what the caregiver would term as 'early established labour', or the 'latent phase' of labour. It is from this time that the caregiver usually records the 'starting time' of labour.

For some women, this change is obvious. Their contractions 'step up', they become stronger, last longer and are more frequent. For others, it may be more of a subtle change with the woman (and sometimes even the caregiver), not being aware that her labour has taken this change, progressing into a new phase. The change may not be that noticeable because they have been gradual, or in some cases the woman does not react very differently, to the more intense contractions.

Occasionally, prelabour can move into the early 1st phase, and then into the active phase of labour, reasonably quickly. Some women may even 'skip' prelabour (or the early 1st phase) and move straight into the active 1st phase, starting off with regular, strong contractions, with little pre-warning. More often than not though, there is a definite build up, giving the woman plenty of time to prepare, or move to her place of birth, without the need to rush.

The change, or 'stepping up' into early, established labour, can happen within an hour or two after the prelabour commences, or after many days. The length of time is very individual for each woman.

Contractions

Throughout the early, active and transitional phases of 1st stage, the uterine muscles contract and retract. Therefore, after each contraction, the individual uterine muscle cells become shorter, making the uterus smaller in size and pushing your baby down and out. During a contraction the uterus tilts forward and downwards. At the same time, the cervix becomes thinner, being pulled up and open (or 'dilating').

Labour contractions normally behave in a progressive way. They usually start off in prelabour being short (20-30 seconds), mild and irregular (or more than 5 minutes apart), changing as the labour becomes more established. In the early 1st phase, the contractions tend to become longer (40-70 seconds), more intense, and usually less than 5 minutes apart. However, some labours do not follow this pattern. Occasionally, a woman will have no build up, and at times she may labour until her baby is born with only moderate, 5 minutely contractions, that would normally be associated with prelabour, or early 1st stage.

The following information describes a range of contraction patterns, which are usually associated with the early 1st phase. It is meant as a general guide only, as some phases do not exhibit obvious changes. The descriptions given here, as well as for the other phases, should reflect the majority of labours.

Early 1st phase contractions may present as:

  • The mild (or painful) period cramping of prelabour, changing into more definite pains that start, build up to a peak, and then fade away. The contractions become more regular, developing a definite rhythm. Contractions would be approximately 3- 5 minutes apart, lasting for approximately 40-45 seconds.

  • Mild (or moderately painful) contractions that have been irregular, short or far apart, becoming more painful, regular, longer and more frequent. They could be mostly strong, long contractions lasting 40-50 seconds every second or fourth contraction, with mild ones in between.

  • Contractions that remain irregular but become stronger, as you notice the intensity building. These contractions may remain irregular (3-5-7 minutes apart) for some time yet.

  • Feeling strong from the very beginning. Some contractions may start with one coming every five minutes (and lasting 40-50 seconds) or you may wake to strong, regular and frequent contractions, because you have slept through the beginnings of prelabour. (This is ideal, as you have rested while your body has done some of the work!)

  • Changing over a period of time, becoming closer together, and last slightly longer, as they move from 5-10 minutes apart or more, to being about 4-7 minutes apart, and lasting for approximately 40- 50 seconds.

  • Becoming stronger after the waters break (or are broken by the caregiver, called an 'ARM' to augment the labour), making the contractions that follow more intense, frequent and longer.

  • Not eventuating, that is the prelabour stops! If you are at home, rest if you are tired, go back to bed and try and sleep. If you feel rested and it is daytime, consider going for a walk to try and restart the labour. Be sure to eat and drink to keep energised and hydrated. If the house is full of visitors, maybe it is time for them to leave! (A watched kettle never boils!)
First baby.

If it is your first baby, then you will more than likely be expected to spend this early 1st phase at home. You may wish to contact your caregiver or hospital delivery suite or birth centre staff, to let them know that "It has started and is happening."

If your partner is at work, it may be good to have them at home now to support you, as the contractions become stronger. You may also wish to contact any extra support people, so they can plan their day (or night). You may not necessarily need them at this point, so if it is 2am in the morning, let them sleep, and contact them when you really need them to come. (They would only lie awake waiting for the next call anyway!).

Second, or subsequent baby.

If it is your second or subsequent baby, you will probably need to contact your caregiver and move to your birthplace soon. Unlike first labours, it is more likely that you will progress more quickly and move straight from this phase into transition, (skipping, or having a very short active 1st phase of labour). It is possible for you to dilate up to 6- 8cms during this early phase, before the contractions become very painful (rather than only 3 - 4 cms like first time around). It is probably a good idea to get to your birthplace soon, before the contractions become too painful (and you need to stop and breathe through them to cope).

Active 1st phase is viewed as the time when the woman's labour changes again, from being in early 1st phase, and moving into what the caregiver would term as 'strong established labour'. Again, the labour 'steps up', with the contractions becoming stronger and closer together, and possibly lasting longer.

As the woman, your body is working very hard now to open up your cervix. The contractions need to be strong to achieve this. (You may be wondering how much more intense this labour can get?) Pain relief options may be crossing your mind. You may notice that you need to breathe through them and work with the contractions now. In many cases, the woman's breathing becomes deeper, her awareness goes inward, and she no longer is able to talk during a contraction.

ACTIVE 1st PHASE IS WHEN THE CERVIX OPENS UP FROM ABOUT 3-4 cm TO AROUND 7-8 cm. 

Active 1st phase is viewed as the time when the woman's labour changes again, from being in early 1st phase, and moving into what the caregiver would term as 'strong established labour'. Again, the labour 'steps up', with the contractions becoming stronger and closer together, and possibly lasting longer.

As the woman, your body is working very hard now to open up your cervix. The contractions need to be strong to achieve this. (You may be wondering how much more intense this labour can get?) Pain relief options may be crossing your mind. You may notice that you need to breathe through them and work with the contractions now. In many cases, the woman's breathing becomes deeper, her awareness goes inward, and she no longer is able to talk during a contraction.

The contractions in the active 1st phase usually become longer (and more frequent), or they may be similar in pattern to the early 1st phase. The difference here is normally the intensity of them, in that they are stronger and usually take more of the woman's energy to deal with them.

Active 1st phase contractions may present as:

  • Being strong, regular contractions coming every 2, 3 or 4 minutes, and lasting more than 45 seconds (but less than 70 seconds).

  • Being a combination of strong and mild contractions, coming from 2 to 7 minutes apart, with every second contraction being stronger than the ones in between. It is not uncommon for the stronger contractions to follow a longer break, and the milder contractions to come soon after the strong one.

  • Being very painful, and at times making the woman wonder how much longer she can do this for. Some women describe them as "Bringing you to your knees", literally!

  • Demanding the woman's full attention, being unable to talk during a contraction.

  • Turning the woman's focus inward, with breathing becoming deeper as she needs to go deeper into herself. (You are more likely to need your partner or support person with you now.)

  • The contractions stopping, while on the way to the hospital or on arrival. Moving from home to the birthplace, (and being anxious or excited) can release adrenaline hormones, capable of slowing, or stopping, contractions. For many women, if they are given an hour or so to resettle into their birthing environment, the contractions will often return to their previous pattern. Often setting up the room comfortably, eating or drinking something and waiting a while will see the contractions return, as the woman relaxes.

  • The contractions stopping, but not restarting. If this happens you may be presented with the options of:
                                  * Going back home until the contractions restart. 

                                  * Being able to rest and 'wait and see'. The lull may be a natural resting phase in your labour. 

                                  * Being induced or augmented by breaking the waters or putting up an oxytocin drip.


The latter may be the favoured choice by many caregivers, (especially if they have issues about time limits). Studies have shown that the longer you are in hospital, the more likely the chance that your labour will end up being medically managed. On the other hand, you may want to 'get the show on the road' and are happy to accept these interventions. Be aware that while medical interventions can be beneficial if appropriately used, unnecessary interventions can carry unwanted risks.



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