HEALTH COLUMN: Signs of labour

Birthing with Bridget

HEALTH COLUMN: Signs of labour

The most common time for your waters to break is when you are well established in labour.

Hello everyone, I hope this article finds you all safe and well. Today we are going to talk about the signs of labour.
The start of labour is different for every woman. There is no exact or definitive route into labour.
When you have made it through most of your pregnancy and are in the final stretch you enter the waiting game of waiting to go into labour.
This can be nerve wrecking for two reasons; firstly, you do not know when you are going to go into labour and secondly, you do not know how to tell that you truly have started labour and it isn’t just a false alarm.
This article aims to explain the signs of labour. It is unlikely that you are going to experience all these signs, and some of these signs may happen to you but go unnoticed.
Your pregnancy is measured in weeks and the 40th week mark is called your due date. This date is not an exact science, but more of an estimation of when your baby will arrive. It is estimated that only 4% of first babies, in Ireland, are actually born on their due date.
Premature is used to describe a labour or baby that arrives early. Once your pregnancy has reached 37wks gestation then it is medically defined as full term. Anything below 37wks is referred to as premature.
If you break your waters at 37wks+1 day, then medically your pregnancy is full-term, even though you are almost 3weeks shy of your due date.
Premature waters breaking, called premature rupture of membranes, and premature pains, called premature labour are uncommon but they do happen. 1 in 16 women will have a premature birth.
Over 4,500 babies are born prematurely in Ireland every year (on average there are 61,500 babies born in Ireland per year). Regardless of your due date, or how many weeks pregnant you are, if you are experiencing pains and/or are fearful your waters are broken and you are concerned about premature labour, contact your local maternity unit for advice.
Babies are viable, this means that they can survive outside of the womb from 24wks onwards. Even though they are viable, this does not mean that we want to see them in the outside world.
In general, the more premature a baby is, the greater the chance is that they will have health problems.
Reaching 24wks in your pregnancy is a milestone, getting to 37wks well and healthy is another great milestone.
I believe that 1st time babies are often nice and comfortable inside their Mum’s wombs and in my experience 4-5 days over your due date is often when labour starts for 1st time Mum’s.
If this is your 2nd or subsequent pregnancy, you will often start this labour like you did a previous labour.
The research tells us, if you had a premature labour before then you have an increased chance of having a premature labour in your next pregnancy. Often, your 1st labour is your longest and slowest labour.
Your body has never done this before, and it is learning. I say it is like going on a drive, somewhere you have never been before, the first time you drive there you will often get lost and are slow.
Second time around you know where you are going and you are much faster. 1st and 2nd time vaginal deliveries are much the same.

Braxton Hicks versus True Labour Contractions
Braxton Hicks’ contractions are sporadic “practice” contractions that many pregnant women experience during their 2nd or 3rd trimesters.
They get your body prepared for the event and can give you an opportunity to practice your breathing techniques.
Women often report that Braxton Hicks feels like their lower abdomen and womb are tightening or simply getting a gentle squeeze and then relaxing. This mild tightening should be uncomfortable rather than painful.
Braxton Hicks are irregular, and they will taper off or disappear and they will NOT get stronger.
Some things can trigger Braxton Hicks, these include, if Mum or baby are very active. A full bladder. After sexual intercourse and dehydration.
Dehydration can be a major cause of Braxton Hicks as your lower abdomen muscles can spasm with dehydration and can cause tightening or discomfort. It is really important to stay well hydrated in pregnancy.
Braxton Hicks can be uncomfortable but should not be painful. They do not cause labour or open the cervix. They do not harm the baby in any way and some research says that Braxton Hicks actually tones your uterus and promotes the flow of blood to your placenta.
Some things can help reduce Braxton Hicks. These include staying hydrated, do not put off going to the toilet as a full bladder can cause Braxton Hicks. Changing positions can help. A warm bath or shower will also relieve Braxton Hicks.
Telling the difference between Braxton Hicks and true labour is important. Here are some questions to ask yourself:
1. How often are the contractions?
Braxton Hicks will be irregular, and they do not get closer or stronger. True labour contractions will come at regular intervals and get stronger, longer, and closer together.
2. Do your contractions change when you move?
Braxton Hicks will stop when you change position. If you were sitting, get up and walk around and they should go. Likewise, if you were walking, lay down and rest and Braxton Hicks should ease. With real labour, the pains will come regardless of your position.
3. Ask yourself how strong the contractions are?
This will be different for everybody. With Braxton Hicks the pains will be weak and will not get stronger. With true labour the contractions will get stronger and stronger as time goes on.
4. Where do you feel the pain or discomfort?
Usually with Braxton Hicks you will feel it only in the front of your abdomen or pelvis. True labour contractions may start in your lower back and move to the front of your abdomen or start in your abdomen and move to your back, rather than just being in the one spot like Braxton Hicks. With real labour your back is normally involved.
The absolute take home message to distinguish between Braxton Hicks and true labour contractions is that real labour contractions will get longer, stronger, and closer together.
Regardless of the discomfort being from Braxton Hicks or from real labour contractions, you should feel good foetal movements throughout. Foetal movements are so important and are the single best indicator of your baby’s well-being.
My mantra is if you are concerned about your baby’s movements, never delay contacting your GP/midwife or local maternity unit immediately for advice.
There is no definite test that you can do at home to be sure the Braxton Hicks are not preterm or full-term labour. If you are concerned that the pain you are feeling is more than Braxton Hicks, then do not hesitate to contact your local maternity unit.
A midwife will chat to you over the phone, and it is likely that they will ask you to come in for an assessment, especially if you are under 37wks gestation (preterm).
In the maternity unit they may assess the strength of your contractions by using a monitor called a CTG (cardiotocograph), it also records baby’s heartrate (much like the printout of an ECG in an adult).
This monitor looks for uterine activity, to see if your womb is contracting. Your womb will contract in real or threatened preterm labour, but your womb will not contract with Braxton Hicks.
Your hospital doctor or hospital midwife may also perform a vaginal examination to assess the cervix to see if it is starting to prepare for labour or if it is dilating.
A woman, even a 1st time Mum, should trust her own gut feeling regarding preterm labour. Women know their own bodies and women know and feel the difference between Braxton Hicks and real labour contractions.

Baby Engaging or “Lightening”
Engagement or your baby “dropping” down into your pelvis usually occurs for 1st time Mums around 36-37wks. The sensation that some women feel as their baby actively moves deep into the pelvis is called “lightening”. When the baby engages in the pelvis it is nested deep down in Mum’s pelvis and it is unlikely that the baby’s head will come back up into the Mum’s abdomen again. Engagement is a sign that the baby is getting ready for the pending labour.
Women often get some relief when the baby’s head engages. Mum’s may feel that it is easier to breath, their heartburn may improve, and they may not feel as heavy.
However, Mums may feel much more lower abdomen pressure and often much more pressure is placed on their bladder making Mum need to go to the toilet even more.
Engagement rarely happens at 36-37wks in your 2nd or subsequent pregnancy. Often when you have had a vaginal birth or births before, engagement happens just before or at the very start of your labour.

Nesting
Nesting during pregnancy is the overwhelming desire to get your home ready for your new baby. The nesting instinct is strongest in the last weeks coming up to delivery. Some women feel a constant sense of restlessness.
Other women get a sudden burst of energy and they want to get things finished that they had started in the pregnancy. A strong desire to nest, clean and prepare has long been regarded as a sign that labour is coming.
It is great to be active and mobile, but it is not a good idea to expel all your energy before labour starts. Absolutely be active, but rest and relax too.

Nausea and Diarrhoea
Some women feel nauseated or vomit before they start to labour. It is thought that nausea happens at the start of labour, for some women, because the digestive system reduces in function during labour, because your body does not want to waste energy.
Our bodies are very clever, and they know they need to conserve as much energy as possible, for the marathon that is labour. Women often experience diarrhoea or loose bowel movements prior to going into labour. This clears out your digestive system.
Prostaglandin is the hormone that is responsible for the softening of your cervix. Prostaglandin can also trigger contractions in your bowel, and this can cause loose stools or diarrhoea prior to labour. If you feel sick or are having loose stools, you may not feel much like eating.
Staying hydrated and sucking on glucose sweats can help keep your energy up. If you feel well and feel hungry, absolutely have something to eat. Little and often and snacks are a good idea, stay hydrated.

Show
The show maybe called your mucus plug, a bloody show or medically referred to as the operculum. These are all different names for the same thing. Your womb is like an upside-down pear.
The round bit is the womb and the long thin bit is the neck of the pear, same as your cervix is the neck of your womb. In pregnancy the cervix is closed to prevent premature labour and ascending infection (infection travelling upwards). Before active labour, and especially on your 1st vaginally delivery, the cervix must ripen, thin, and soften.
This is referred to as effacement, the preparing of the cervix to labour. Effacement goes relatively uptalked about, but it is such an important part of early labour, especially on your 1st vaginal birth.
Often just before or during the effacement of your cervix, you will pass your show. Not every woman passes a show. Some pass only one show, some women have a few shows, especially when they wipe, and other women have none.
The show is not pretty. It is slimy and sticky and gooey. It can contain blood or be pink stained.
The show is never heavy or fresh, active blood. This is a bleed and is very different. If you are passing fresh blood like a period, then you need to contact your local maternity unit. Your show is a sign that your body is preparing for labour, but it is not a concrete sign that labour will start immediately.
Note the time that the show has happened at. Take it as a positive sign, but don’t over think it. If you pass a show you can stay at home until your pains start or your waters break, provided you are above 37wks gestation and that your baby is moving well.
If you have had a vaginal examination, you will likely get a show sometime after the examination. This may mean that the body is preparing for labour, or it could be as a direct result of the internal examination. Time will tell.

Group B Strep (GBS)
Group B Streptococcus is NOT a sign of labour. However, I believe it needs to be discussed and explained as women who have GBS are often told they need to come to the hospital immediately if their waters break or if they feel they are in labour because they need IV (drip) antibiotics in labour because of the GBS.
GBS is a common type of normal flora carried without any symptoms by approx. 30% of the populations in the intestines and by 25% of woman vaginally. It is not a sexually transmitted infection. GBS usually causes no harm. GBS is not routinely screened for during pregnancy in Ireland.
This is because it is transient, it can be here today and gone tomorrow. So, a negative test, a few weeks before labour, can give you a false negative result.
GBS can be passed from a Mum to her baby. If this happens the baby may just be a carrier of GBS, which is harmless.
However, very occasionally, GBS can cause illness in new-born babies, this is known as GBS infection. Very occasionally, GBS causes urinary tract infections in women during pregnancy, these are rare and need to be treated with oral antibiotics. More often, GBS is detected in a vaginal swab.
This makes us aware that the Mum is a carrier of GBS, this does not need to be treated antenatally, but it is noted on the women’s file, and she is informed.
She will require IV antibiotics when her waters break or during labour, and her baby will be monitored closely by the midwives on the postnatal ward for signs of infection for 24hrs post-delivery. Provided the baby is well, baby will stay with Mum and this monitoring will occur at the bedside.
Some babies are at more risk of developing GBS infections. These babies include babies born to Mum’s who we know had GBS in their pregnancy. If you had a previous baby with a GBS infection.
If a Mum has a high temperature during labour. If you go into labour prematurely, especially if your waters break before 37wks and if you give birth more than 18 hours after your waters have broken.
In most maternity units, these are all reasons to give Mum IV antibiotics during labour and to monitor baby closely for 24hours post delivery for any signs of infection.
Breastfeeding does not increase the risk of GBS, and it prevents against other forms of infection. New-born babies with any signs of GBS infection will be treated with IV antibiotics straight away.

Waters Breaking
This is medically called the rupture of your membranes. The water around your baby is called the amniotic fluid or liquor. In TV land this is always how labour starts, but not in the real world. Waters breaking before your labour pains start only occurs in approx. 5% of all pregnancies above 37wks.
The most common time for your waters to break is when you are well established in labour. There is one bag of waters around your baby, and your baby’s head separates this into the big bag in front of your baby’s head, the forewaters, and the part of the waters behind your baby’s head called the hind waters.
Your waters breaking happens when this bag of fluid starts to leak or break with a gush. You may feel a slow trickle or a sudden gush of water that you cannot control.
Generally, if it is a big gush and very evident, it is the forewaters and if it is trickling it is likely to be the hind waters. Try to remember the word TACO, T is for the time that the water breaks at, A is for the appearance of the waters, C is for the colour of the waters and O is if there is any odour from the waters (waters should be odourless). It is a good idea to note these 4 things. The waters should have a clear or straw-coloured appearance. Sometimes they are pink because they have mixed with the show. The waters can be a green/brown colour or foul smelling. We do not want to see a green/brown colour as often this means that your baby has opened its bowels in the womb.
When your waters break you will always contact and then go to your local maternity unit. If you see green/brown or red bloody waters, you should go there immediately with no delay, don’t even worry about ringing first, if you cannot get through via phone, start making your way to the hospital and telephone again on the way.
When the waters break, it is often obvious as you have soaked your clothes or bed. The waters do not stop coming, big gushes at the start and then constant drainage, this is because the placenta keeps making the water.
However, for some women it is much more subtle. Many women experience a feeling of dampness. If you feel that you must wear a bigger than normal sanitary pad and that sanitary pad is feeling damp, change everything and observe, if this happens again then your waters maybe trickling. It is safer to contact your local maternity unit for advice.
There should be no odour from your waters, don’t be afraid to smell and see. It is important at any gestation, to establish if your waters have broken.
The water comes out, but infection can also go in when the waters are broken, that’s why it is important to establish whether they have broken or not. When your waters break you need to go to your local maternity unit for assessment.
If you are above 37wks gestation, you are full term and you will be hoping that your labour will start. 60% of women will labour within 24hours of their waters breaking.
If you do not labour, then your maternity unit will discuss induction of labour with you.
After 18 hours of your waters being broken, if your baby is not delivered, you will be offered IV antibiotics to help to prevent infection.

Pains
I left the best until last!!! Contractions are the only definitive sign that labour maybe underway. True labour pains get longer, stronger, and closer together. You will want to monitor 3 things, how often the pains come (from the end of one pain to the start of the next), how long the pains last when they are there and what time approx. the pains started at.
There is no single timeline that applies to all women. Your previous labours and how your other babies were born will have an impact, or if this is your 1st baby. Generally, 1st vaginal labours are slower as effacement (the thinning, softening, and preparing of your cervix) must happen first and then dilating occurs. In your 1st vaginal labour, these phases happen separately.
However, if you have had a vaginal birth before then effacement and dilation will happen together, making your 2nd or subsequent vaginal births faster.
Most maternity units ask women to contact them when they are having pains every 10 minutes, lasting for greater than 45seconds, and these pains will have been present for longer than a few hours.
Remember that if your waters break, if your baby is not moving as you would like or if you have fresh vaginal bleeding then you need to go to hospital regardless of pains.
Your hospital midwife will chat to you via the phone and will discuss your history and a plan will be put in place. If you have had a previous C-section and are planning a C-section for this birth, then you need to contact your maternity unit as soon as you get pains.
If you know that your baby is in a breech position and you are having a planned C-section then you need to contact your maternity unit immediately if you think yours waters may have broken or if you have any pains at all.
Likewise, if you are carrying twins. If you have had a previous C-section and are planning a vaginal birth (VBAC- vaginal birth after C-section), contact the hospital for advice when you start to get pains because you have a scar on your womb, from your previous C-section, your hospital midwife will likely ask you to come in for assessment earlier.
Effacement is the preparation of the cervix and as we have mentioned, it is especially important in your 1st vaginal birth.
In my experience, effacement pains are felt in your lower back, and they come like a deep V-shape around the front of your abdomen, below your bump.
They are all low, not high up your bump and women often describe them as strong period like pains. If baby is moving, your waters are intact, you are not bleeding, and you are coping well then it is ok to stay at home with these effacement pains on your 1st baby.
Remember 2nd or subsequent babies come much faster than 1st babies, so do not delay 2nd time around if you are getting strong pains.
Some women especially 1st time Mums, have irregular pains for a whole day before they are in active labour. Other women get good regular pains from the start. Trust your gut, even on your 1st baby, you know your own body.
I believe it is all about coping and feeling safe. Your local maternity unit is there to advise and guide you, don’t be afraid to call them to ask for advice.
A midwife will often know by chatting to you on the phone whether you need to come into the hospital or not.

THE TAKE HOME MESSAGES
When to go to hospital?
-when your contraction pains become longer, stronger and closer together.
-you feel that it is now time to receive support from a midwife.
-if you feel uncomfortable or generally unwell.

OR if any of the following occurs, go straight to hospital.
-if you have reduced baby movements.
-if the waters break, even if you are not sure, go into the hospital to be assessed.
-if the pressure sensation is building up and you are starting to feel like you need to push / or empty your bowels.
-if at any time you feel unwell.

I hope you have enjoyed this article and more importantly, you have found it beneficial. Remember these points are just a guide, if you are concerned about anything speak to your GP/midwife, or local maternity unit.
If you would like to contact me, please send me an email at birthingwithbridget@gmail.com. Next week we will follow on from this article and we will discuss the 1st stage of labour.

Until then,
Take care,
Bridget the Midwife.

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