How labour starts · The First Year, Day by Day

Nobody knows exactly what flips the switch. It seems to be a conversation between your baby, the placenta and your body, building over days or weeks. For many people the start is gradual and a little confusing. This chapter explains what is happening, the signs to watch for, how to time contractions, when to call, and how to spend early labour at home.

The hormones of labour

Three hormones do a lot of the work, and knowing about them helps explain why the place and people around you matter.

Oxytocin makes the uterus contract. It is released in pulses from the brain, and its levels rise as labour builds, peaking at the birth. It is the same hormone involved in love, touch and breastfeeding, and it flows best when you feel safe, warm, private and unhurried.

Endorphins are your body's own pain-relieving hormones. They build up as labour gets stronger and can give a dreamy, inward-looking feeling between contractions. They take time to build, which is one reason labour that starts gradually is often easier to cope with than you might expect.

Adrenaline is the "fight or flight" hormone. In early labour, a lot of it (from fear, bright lights, a cold room, feeling watched or rushed) can slow contractions down. This is why some people find their labour stalls when they arrive at hospital and picks up again once they settle in. Right at the end of labour, a surge of adrenaline is normal and useful: it gives you energy and alertness to push your baby out.

You cannot control your hormones, but you can help them along by keeping your space calm, dim and warm.

Prelabour and the latent phase

In the days or weeks before labour, many people have prelabour: irregular tightenings that come and go, perhaps for a few hours in the evening, then fade. They may be uncomfortable and they are doing useful work, softening and moving the cervix forward, even if they do not open it much. The latent phase, or early labour, is when contractions become more regular and the cervix starts to thin and open, up to about 5 or 6 cm. For a first baby this can last many hours, sometimes a day or more, often with stops and starts. For later babies it is usually shorter. "The first stage: early and active labour" explains what happens next.

Signs that labour may be starting

No single sign means labour is definitely starting, and you may have all of them or none. The clearest sign is regular contractions that get longer, stronger and closer together.

The show

The cervix is sealed with a plug of thick mucus during pregnancy. As the cervix softens and starts to open, the plug comes away, either in one blob or bit by bit. It may be clear, creamy, or streaked with pink, red or brown, and is called a "show". Labour can follow within hours, or not for a week or more. A show on its own is not a reason to go in.

Call your midwife or doctor if the bleeding is more than streaks or spotting, if it is bright red and keeps coming, or if you are under 37 weeks.

Waters breaking

Your baby is surrounded by a bag of membranes filled with amniotic fluid. When the membranes break, the fluid leaks out. For most people this happens during labour, often late in the first stage. For about one in ten, the waters break before contractions start.

It may be a sudden gush, or a slow trickle that keeps you damp. Amniotic fluid is usually clear or pale straw coloured, often slightly pink-tinged, and smells faintly sweet or of nothing much. It keeps leaking, especially when you stand up or move. Urine, by contrast, smells of urine and usually stops, and normal pregnancy discharge is thicker and whiter. If you are not sure, put on a pad, lie down for half an hour, then stand up and see whether more fluid comes.

What happens next depends on your situation, so call your midwife or birth unit whenever you think your waters have broken, even if you have no contractions. They will ask about the colour, smell and amount, and whether your baby is moving well. They may ask you to come in to confirm it and check on you and your baby, or, if all is well, to wait at home for a while. Most people go into labour on their own within 24 hours. If labour does not start, you will be offered induction, sometimes sooner, because the risk of infection rises slowly the longer the waters are broken (see "When labour needs help"). Once your waters have broken, use pads, not tampons, avoid sex and baths unless your care provider says otherwise, and check your temperature every few hours.

Contractions or Braxton Hicks?

Braxton Hicks tightenings are practice contractions that can start in mid-pregnancy. Labour contractions are different in a few useful ways. Braxton Hicks Labour contractions

Pattern Irregular, do not get
closer together
Become regular and closer
together

Strength Stay the same or fade Get stronger over time Length Usually under a minute,

Early contractions often feel like period cramps that come and go, or a low backache that builds and fades. Your belly goes hard during them and softens in between.

Other signs

Back pain: a dull, low ache that may come and go with tightenings, or stay. Some people feel most of their labour in the back, especially when the baby is facing forward.

Loose stools: hormones that soften the cervix also loosen the bowels, so diarrhea or several bowel movements in a day can come shortly before labour.

Nausea, a burst of nesting energy, or deep tiredness.

Timing contractions

Time your contractions from the start of one to the start of the next. That is the "frequency", how far apart they are. The "length" or "duration" is from the start of one contraction to its end. A notepad or a contraction-timing app both work; your support person can do this so you do not have to. You do not need to time every contraction for hours. Time a few in a row when things seem to change, and notice whether you can still talk through a contraction.

When to call

Your care provider will give you their own guidance, and you should follow it. As a general guide, many care providers suggest that people having a first baby call when contractions come about every 5 minutes, last about a minute, and have done so for about an hour. This is sometimes called the 5- 1-1 rule. Some providers use other versions, such as about every 3 minutes, lasting a minute, for an hour.

Call sooner if this is not your first baby, since later labours are usually faster; if you had a fast labour before; if you live a long way from where you plan to give birth; if you are planning a home birth; if you have been told you are Group B strep positive; or if you simply feel you need advice or support. You never need a reason to call.

Figure 3. Timing contractions: from the start of one to the start of the next.

When to call or go in right away

Some signs need prompt attention, whatever is happening with contractions. Get help right away if:

Your waters break and the fluid is green, brown, or yellowish, which may mean your baby has passed meconium (their first stool), or the fluid smells bad.

You have bleeding that is more than a streaky show, or bright red bleeding.

Your baby is moving less than usual, or movements have changed or stopped.

You have constant, severe pain in your belly that does not ease between contractions, or a belly that stays hard.

You have a fever of 38.0 °C (100.4 °F) or higher, or feel shivery and unwell.

You have a severe headache, changes in your vision, pain under your ribs, or sudden swelling.

You feel something in your vagina or see a loop of cord after your waters break. This is a cord prolapse, which is rare but an emergency. Call your local emergency number, get onto your hands and knees with your head down and bottom up, and stay there until help arrives. You have contractions, a show with bleeding, or leaking fluid before 37 weeks. This may be preterm labour (see "Special situations").

You are worried, for any reason. Trust your instincts.

False alarms and being sent home

It is very common to go in, be assessed, and be told you are in early labour and should go home for now. It can feel deflating, especially after a long night. It is not a mistake to have gone in, and it does not mean you are not in labour. It usually means your labour is still in the latent phase, which often goes better at home, where you can eat, rest, move and feel at ease. People who are admitted in early labour tend to have more interventions without better results for themselves or their babies.

Before you leave, ask what signs should bring you back, and check that you and your baby are well. If you are struggling to cope at home, whatever the timing, call back and say so. Some units can offer you a quiet room, a bath, or pain relief, and how you are coping matters as much as the numbers.

Early labour at home

Early labour is a time to save your energy. Many first labours have a long latent phase, and the people who cope best tend to pace themselves rather than treat the first contractions as the main event.

Carry on, gently. By day, walk, watch a film, bake something. At night, sleep or rest between contractions.

Eat and drink. Light, easily digested food (toast, soup, yogurt, bananas, pasta) and plenty of fluids keep your energy up. Empty your bladder every hour or two.

Use comfort measures early. A warm shower or bath, a heat pack on your lower back, rocking on a birth ball, slow breathing and massage all help. "Coping with pain without medicine" has much more.

Stay upright and mobile when contractions need your attention: leaning on a counter, swaying, kneeling over a ball.

Keep it calm. Dim the lights, keep visitors away, turn your phone to silent, and let your support person handle messages.

Check in with yourself. Keep noticing your baby's movements, and if anything worries you, call.

When contractions are steadily stronger and closer, you need to stop and focus through each one, and you no longer want to chat between them, labour is likely moving toward the active phase. That is the time to check in with your care provider and, for most people, make your way in.

In short

Oxytocin drives contractions, endorphins help you cope, and too much adrenaline early on can slow things down; calm, warm and private helps. Early (latent) labour can last many hours, with stops and starts, and is usually best spent at home.

Time contractions from the start of one to the start of the next; a common guide for first babies is calling at about every 5 minutes, lasting a minute, for an hour, sooner for later babies or if you live far away.

Always call if your waters break, and get help right away for coloured or smelly fluid, bleeding, fewer movements, constant pain, fever, a cord in the vagina, or signs of labour before 37 weeks.

Being sent home in early labour is common and often the best place to be; go back whenever you need to.