Arriving at Hospital Too Early in Labour

What "too early" means

It is a definition, not a judgement. NICE sets out two stages of early labour:

• The latent first stage is "a period of time, not necessarily continuous, when there are contractions and there is some cervical change, including cervical position, consistency, effacement and dilatation up to 4 cm".
• The established first stage is "when there are regular contractions and there is progressive cervical dilatation from 4 cm".

Arriving "too early" means arriving in the first of those. It is extremely common, it is not a mistake, and both the NHS and Tommy's tell you to phone whenever you think you are in labour or are unsure. The NHS is explicit about the possible outcome: "If you go into hospital before your labour has become established, they may suggest you go home again for a while."

The assessment you should get

NICE does not describe a quick look and a decision. It describes a proper assessment.

Recommendation 1.8.3: carry out a face-to-face early assessment of labour either at home, regardless of planned place of birth, or in your planned place of birth, "comprising one-to-one midwifery care for at least 1 hour".

Recommendation 1.8.4 says any early or triage assessment should include:

• Asking how you are, and about your wishes, expectations and any concerns.
• Asking about your baby's movements, including any changes.
• Giving information about what to expect in the latent first stage "and how to work with any pain she experiences".
• Giving information about what to expect when you access care.
• Agreeing a plan of care with you, "including guidance about who she should contact next and when".
• Providing guidance and support to your birth companion.

NICE also requires that "the triage midwife should document the guidance that she gives to the woman". If you leave without a plan and a number, something has been skipped.

What the midwife is checking

NICE's initial assessment in labour is detailed, and knowing the list makes the appointment feel less like a formality.

About you: a review of your antenatal notes and screening results, your personalised care plan, any risk factors, the length, strength and frequency of your contractions, the pain you are in and your options for pain relief, your pulse, blood pressure, temperature and respiratory rate, a urine test, any vaginal loss, and whether you need antibiotics in labour for group B streptococcus.

About your baby: your baby's movements in the last 24 hours, and abdominal palpation "to determine the fundal height, the baby's lie, presentation, position, engagement of the presenting part, and frequency and duration of contractions". The baby's heart rate is listened to "for a minimum of 1 minute immediately after a contraction", with your own pulse felt at the same time to be certain the two are being told apart.

That is a substantial assessment, and it is the reason the visit is worth making even if you are sent home afterwards.

The vaginal examination

This is the part people dread, and NICE's position is more permissive than most people realise.

On whether it happens at all: "If there is uncertainty about whether the woman is in established labour, a vaginal examination may be helpful after a period of assessment, but is not always necessary. If the woman appears to be in established labour, offer a vaginal examination."

On how it should be done, NICE instructs staff to be sure the examination is necessary and will add important information, to "recognise that a vaginal examination can be very distressing for a woman, especially if she is already in pain, highly anxious and in an unfamiliar environment", to explain the reason and what is involved, to ensure informed consent, privacy, dignity and comfort, and to explain the findings sensitively.

And, in plain terms: "advise the woman that she can decline the examination before it starts, or ask to stop at any stage during the examination."

The NHS says the same: "Your midwife will offer you regular vaginal examinations to see how your labour is progressing. If you do not want to have these, you do not have to."

What they are deciding

Not whether you are exaggerating. NICE is explicit that painful contractions and cervical change are two different things:

"If a woman seeks advice or attends a midwifery-led unit or obstetric unit with painful contractions, but is not in established labour: recognise that a woman may experience painful contractions without cervical change and offer her individualised support and analgesia if needed; encourage her to remain at or return home, unless doing so leads to a significant risk that she could give birth without a midwife present or become distressed."

Two things follow from that. Pain relief is available even when you are not in established labour, and the instruction to go home is not absolute — it has a written-in exception.

Why they do not simply admit you

Tommy's gives the reason and hedges it appropriately: "Some evidence suggests that if you stay home until you're in established labour you're likely to have fewer interventions. But do talk to your midwife about what you'd prefer and where is the best place for you to be at this time."

The HSE's account of arrival is more matter-of-fact: "A midwife assesses you when you arrive. They talk to you about what signs of labour you have. They may offer to do a vaginal (internal) examination to see how your labour is progressing. If you are still in early labour you may be told to go home until labour becomes stronger. If you live far away from hospital this might not be an option."

That last sentence is worth remembering. Distance is a legitimate reason to stay.

What to ask before you leave

• How dilated am I, and what else changed besides the number?
• What exactly should bring me back, and how soon?
• Who do I ring next, and on what number?
• What pain relief can I have at home?
• If I cannot cope at home, what happens?

NICE expects a plan of care and a documented contact point, so all of these are questions the guideline says you should already have been answered.

What overrides all of it

None of this applies if something else is going on. The NHS lists the reasons to call urgently regardless of how dilated you are: your waters breaking, vaginal bleeding, your baby moving less than usual, being under 37 weeks, any contraction lasting longer than 2 minutes, or 6 or more contractions every 10 minutes.

When to call someone

• Your midwife or maternity unit before setting off, whenever you think you are in labour or are unsure. NICE expects telephone triage first, to decide whether a face-to-face assessment is needed.
• Urgently for any of the NHS list above.
• Again, without embarrassment, if things change after you get home. You are not limited to one call.
• Your local emergency number — 999 in the UK and Ireland, 911 in the US and Canada, 000 in Australia, 111 in New Zealand — if you feel a strong urge to push and think the baby is coming.

The short version

Going in before 4 cm gets you an assessment, not a bed, and NICE expects that assessment to last at least an hour and to end with a written plan and a phone number. The examination is offered rather than required, pain relief is available even in the latent phase, and the instruction to go home has a built-in exception if you could not safely or bearably be there.