Warm-Up Labour
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[Jayne] I'm writing this article from a personal perspective. Now, I wouldn't normally bang on about ‘what happened to me' because a) it's really boring & b) everyone & every birth is different. However, I believe that if I had not had the one-to-one midwifery care from Cassy with my last birth, I may have had a very different experience and it's likely there are others out there who will benefit from reading about variables in the build-up to a normal birth. Cassy's going to add bits from a Midwife's perspective in purple.

I also wanted to address the sticky subject of what ‘does' or ‘does not' constitute labour. Many health professionals refer to ‘established labour' as being defined when a woman's cervix dilates to 3cm – in other words ‘you're not properly in labour' until someone examines your cervix vaginally & tells you that you are.

Well, frankly, I find that approach rather patronising & somewhat deflating. Similar to not officially recognising that you're pregnant until you reach the golden 12 week milestone, the ‘there there dear, it's not proper labour' mentality is one of most vociferous bees in my rather large & overcrowded bonnet.

[Cassy] Of course the other way of looking at this is to consider the fact that in the UK and USA labour is supposed to follow the same pattern for all women. Any deviations from a medically-determined length of labour, rate of cervical dilation and contractions is deemed as abnormal and requiring medical intervention - usually in the form of syntocinon (called pitocin in the US). So in a way, using terms that indicate that this is not the part of labour that will result in a birth that day or night prevents unnecessary medicalisation of normal births. This of course is not usually explained to women so they can feel tired, disheartened, unsupported and start to believe that there *is* something wrong with them! Negating what an individual woman's experience is by giving the impression that what they are experiencing is not ‘real' or is not causing them anxiety or pain does not make them feel supported or confident.

It drives me bonkers when my body's substantial efforts pre-3cm are cast aside as utterly unimportant by the phrase ‘but you're not in proper labour' . So, in order to acknowledge perfectly normal but often very tiring events BEFORE your body really ‘goes for it', I've coined the phrase ‘Warm-Up Labour'. I know some people use the term ‘pre-labour' to describe the same thing, but again, I find this just as damning – THERE IS NOTHING ‘PRE' ABOUT FACING MEATY CONTRACTIONS EVERY 10 MINUTES FOR 3 NIGHTS IN A ROW. It is HARD WORK. It is TIRING. And it is a PART OF NORMAL LABOUR.

IT IS THE DRESS REHEARSAL BEFORE THE MAIN EVENT.

IT IS WARM-UP LABOUR.

I didn't get a warm-up labour with my first baby. My waters broke, my contractions kicked off & stayed relentlessly agonising & regular, but unbeknownst to me my baby was in a bad position & therefore his head wasn't applying much pressure to my cervix. That wasn't warm-up labour – that was labour with a badly positioned baby & no proper support.

With my second baby, however, Cassy was my midwife & in the months leading up to the birth she told me on numerous occasions that my birth this time around would probably be a ‘stop-start' affair for a while before my labour really kicked in. I took this on board. Or at least I thought I did.

Over the years I have found it fairly common that many women experience this ‘warm-up' labour - some for even a couple of weeks before baby decides to be born! So I do try to discuss it as a possibility during pregnancy. I also believe that it is more common in women who have had a traumatic first birth. There are numerous terms out there used to describe this part of pregnancy - prodromal labour, pre-labour, irritable uterus, strong Braxton Hicks - but the important thing to remember is that this is NORMAL. It may become disheartening AND exhausting for many women who are not well supported or prepared at this time but I do not believe that something so common in late pregnancy that happens to so many women who then go on to have straightforward vaginal births to a healthy baby is abnormal in the absence of some medical condition.

For some reason, I had it in my head that I may wake up one morning, experiencing mild contractions which may ebb away & return. This might continue for the whole day & then I might go into a more regular labour that night. What I hadn't thought about or read about was the exact nature a warm-up labour might take.

I had had a good ‘show' a couple of days previously, but on the Monday night, whilst watching TV, I started feeling a couple of very mild ‘period pain' type of contractions. I experimented with a bit of nipple tweaking that Cassy had told me would help produce oxytocin (the hormone you need for labour) & every time I attempted to tune a breast into Radio 4, the next contraction would be a lot stronger. I then whipped out an acupressure pen that Cassy had lent me & kept applying it to points on my ankles, which also produced stronger contractions.

It is quite normal to have a show a few days or even more, before labour begins and it's just another sign that your body is ‘warming-up'. Many women feel that starting to do various things; walking for hours, bouncing on birth balls, nipple tweaking, acupuncture, reflexology, sex, pineapple, curry, etc.. etc.. to make contractions stronger and to get labour going is beneficial. I think that if you are having early contractions then what's the rush? You have waited for months so far. As a society we seem to have taken on the very ‘medical' idea that labour should follow a set path over a set period of time e.g. have a show, possibly have your membranes rupture, start contracting, labour over about 12/14 hours for a first baby, less for a second, become 10cms dilated, feel like you need to push at that point, rupture membranes, if it has not already happened, give birth, deliver placenta, breastfeed - and this should all happen within a day or labour is seen as abnormally long!

This view is of course a medicalisation of a normal physiological process that can be longer or shorter for some or more start-stop than for others. After all we are not clones and each woman's body and baby will ‘work' in slightly different ways to each other. My thoughts are that induction is induction is induction - no matter what method is used! Nature is obviously working at its own speed for a reason. If your contractions are not more intense all on their own, then you are probably not ready to birth!

These early contractions are doing a job - thinning out the cervix, helping baby into position, preparing you for a labour that will end in a normal birth. In fact nature is being kind in that it is giving you a break in between doing this very important job. I usually feel optimistic when caring for a woman who has a period of warm-up labour because I know that her body has prepared her and her baby well. Anecdotally I have found that when the mother is ready to birth and baby is ready to be born, then women who have had a good ‘ol warm-up for a while tend to labour very efficiently.

I thought I might be in ‘early' labour. So I got excited. However, by 11.30pm, these irregular contractions had completely disappeared & I went to bed.

From then on I kept a note of my contractions & my warm-up labour went like this:

TUESDAY

2.10am – Woken up with strong Braxton Hicks with period pains every few minutes

2.29am – Big Braxton Hicks

2.33am – Big Braxton Hicks

2.35am – Felt waters trickle while in bed. Went to bathroom & about half a glass of (what I thought was) amniotic fluid splashed on the floor. I put pad in – tiny bit of blood.

2.45am / 2.48am / 2.51am / 2.55am – Braxton Hicks with period pain

3.00am – more like a mild contraction

3.06am – mild contraction

3.12am – mild contraction

3.15am – mild contraction

(no point in going back to bed as you're usually advised – I didn't want to lie down & couldn't have slept through these albeit mild contractions if I'd tried)

3.16am – mild contraction (30 secs)

3.20am – mild contraction (40 secs)

3.27am – mild contraction

3.29am – mild contraction

3.30am – decided to call Cassy – I didn't need her yet, but she lived about an hour's drive away & was worried about her getting stuck in rush hour traffic if things started hotting-up.

I then had mild contractions every 5 minutes. Decided to busy myself getting things ready. At 3.40am I also decided to start filling the pool because even though it would only take half an hour to fill & I certainly didn't need it yet, I'd heard that second labours can sometimes be lightning quick, so I didn't want to miss out on the use of the pool if this happened.

5.00am – Cassy arrived. She reassured me that everything was normal. However, by 6.25am my mild contractions dropped off completely & disappeared. How disappointing. Cassy advised me to go back to bed & get some sleep & she went home so she could return later in the day.

This is fairly common in ‘warm-up' - irregular contractions over night but as soon as dawn approaches it all stops. I think that this is an instinctive response – the woman, her baby and body is not ready to birth yet and it is ‘safer' to not be distracted by contractions during the daylight when the birth is not imminent that day or night. Imagine those pre-historic cavewomen who needed to be alert and foraging during daylight hours before settling into her safe ‘cave' at night where she wouldn't be disturbed. Evolution really hasn't moved on much! We still need quiet, safety and privacy.

I spent the day feeling very cross with myself that I hadn't ‘fallen into' ‘proper labour' the night before & was a bit tearful about it when Cassy popped in to check on me. She was brilliant though & told me that actually my body was doing a lot of the ground work very gently & that this was a very kind way to labour.

Most women find this time in warm-up difficult. I know from experience (my own included) how tired and disheartened you can feel. But I also think that for some women they not only physiologically need to go through this but perhaps psychologically as well as they prepare to face labour. During this time if at all possible (and my other clients/births allow!) I tend to try and spend some time with the woman, either sitting in the garden for an hour, going to the park, out for lunch or an hour or two shopping. I have even been to the cinema a couple of times. It just seems to help, reassure and support, as well as distract (a ‘perk' of being an Independent Midwife is having more time to spend with women). Of course I recognize that if I had 10 other women to see that day, all with equally pressing needs that I would not be able to do this, or if these warm-up periods of labour were going on for a couple of weeks. But I do believe that although spending time is beneficial there is no reason that a woman should feel unsupported at this time - if I really couldn't manage to visit then I would at least phone regularly.

Cassy also said that by the time things really got going I'd probably already be a few centimetres dilated, so the labour would progress more quickly if everything was OK. She also told me that this was a completely normal way to labour for a lot of women & without naming names, she told me about a number of her previous clients who had gone on like this for days before they really ‘got going'.

As I have said already - a VERY common and NORMAL part of labour. It can help to reassure and ‘normalise' this time if women know that it is a common experience.

The best thing I could do, Cassy said, was to eat well, rest & conserve my energy. So I did. Although I was still a bit annoyed – but then, I am an impatient beggar. (I agree!!)

Apart from what I thought was trickling amniotic fluid, I didn't have any other signs or symptoms of impending labour the whole of the Tuesday day or Tuesday evening. I also didn't have to change my panty pad very often with the trickling fluid – not like with my first labour when it gushed constantly & I had to change it every half an hour or so. Cassy started to suspect that my waters hadn't actually gone at all but that I may have experienced something else entirely (I'll let Cassy explain).

Jayne had given me a pretty good description of what could have been membrane rupture, however there were a couple of things that made me begin to doubt that this was the case.

•  The baby was in a really good position with a well flexed head and engaged at this point. I could also feel plenty fluid around baby and Jayne reported very little fluid loss and not having to change a pad often.

•  Continuous contractions that were leading to birth had not begun e.g. she was still ‘warming up'. With a baby in a good position, a well flexed head and engaged I would have thought that contractions would have started. Membrane rupture not followed by labour a few hours later is frequently found in women whose babies are either Occiput Posterior (OP) or in a less than ideal position. I knew that this was not the case with Jayne.

•  There was the possibility of this fluid loss being cervical discharge from the breakdown of collagen in the cervix. Although not reported in any medical texts, most midwives would be able to remember a woman who was positive that her membranes have ruptured and report the same symptoms, only to find intact, bulging membranes in labour or at birth a few days later! Anecdotally many women report a gush of fluid from the vagina in late pregnancy. They are not all incontinent, nor have they all ruptured their membranes, so.....is this some normal part prior to labour that has not been studied or researched yet? There is still much that is not known about the exact nature of what triggers labour, so perhaps in the future some very clever person will work this out! For some more thoughts on this, the following is taken from midwife Ronnie Falcao's Gentle Birth site.

Fluids without Rupture

It is possible to have fluid coming out of the vagina that is not from a true rupture of membranes - some possibilities to consider:

• There are two layers of membranes - the outer sac (the chorion), and the inner sac (the amnion); it is possible for the outer sac to break while the inner sac remains intact; this can still release some fluid that might have accumulated between the layers.  This would tend to be a small amount of fluid, and generally there is not a continuing trickle.
• It is possible for baby to poke a hole through the membranes at some point.  Then, as fluid is released, the sac may double over on itself at that point and, like Saran Wrap, stick to itself, forming a seal over the leak.  Again, this would tend to be a small amount of fluid, and generally there is not a continuing trickle.
• In women over 35, it is very common for the hormones of pregnancy to cause small fibroids to grow larger.  Sometimes they break down during the pregnancy and may release some odd, yellowish discharge.
• I've seen some clients who have a significantly enlarged urethral sponge in late pregnancy; this is the tissue that is alleged to be involved in "female ejaculation"; my reading suggests that fluid from the urethral sponge could be very similar to amniotic fluid.  In theory, fluid could be released simply from the increasing hormones of late pregnancy, without any particular arousal on the woman's part.

If my waters had gone, I didn't want any vaginal examinations as this can increase the risk of infection. I wanted to continue the ‘expectant management' or ‘wait & see' approach & follow NICE Guidelines. I was strangely calm & completely unconcerned about going into labour & knew the NICE Guidelines of 96 hours would take me until the Saturday morning before I had to seriously consider an induction & further intervention.

However, if my waters hadn't gone, then we didn't need to be concerned about the onset of labour at all – if my membranes were still intact then I wouldn't be at risk of infection. Catch 22 – had they gone or hadn't they?

My own thoughts are that if a woman has decided to follow a ‘wait and see' approach after suspected membrane rupture then NOTHING should be introduced into the vagina to try and find out if this is the case or not. Monitoring vaginal loss, temperature taking, asking the mother to be aware of baby's movements, or any changes in them and reassuring foetal heart tones are more important during this time. If we do get to the end of the NICE recommended up to 96 hours then I would suggest a sterile speculum exam (although even this can give a false positive or a false negative result) and possibly an Ultrasound Scan prior to an induction. Obviously if there were any changes in the mother's or baby's condition during this time then I would refer to an obstetrician. However as with all decisions it is the woman's choice to follow any advice that she is given by me or anyone else!

WEDNESDAY

Cassy came to visit during the day to check I was OK & spent a good couple of hours chatting & having tea in the garden. The weather was sunny & warm & over those few days I got a little glow on my cheeks. My husband stayed off work as I needed him close & we all just sat about. Then....

6.50pm – Whopper contraction that came out of nowhere. Had to really concentrate & breathe through it.

7.05pm – another whopper

7.15pm – same again

7.30pm – and again

7.42pm – and again – could this be ‘the night'?

No

8.20pm – contraction – definitely not as strong

9.42pm – weak contraction – went to bed annoyed again

THURSDAY

4.19am – woken up by an intense contraction. They then start coming thick & fast – I had to really concentrate on them all, so my husband took over the logging. 4.21am / 4.27am / 4.32am / 4.38am / 4.43am / 4.48am / 4.53am / 4.58am / 5.02am / 5.06am / 5.10am / 5.12am / 5.17am / 5.19am / 5.22am / 5.25am – shall we phone Cassy? No – she said not until they came every 5 mins regularly & I don't want to call her out unnecessarily again – 5.35am / Stu starts filling the pool / 5.43am / 5.49am / 5.59am / 6.06am / 6.12am – dawn is breaking, my 2 year old gets up, comes into the room & as quickly as they had started my contractions completely disappeared again. Still, at least I'd managed to test out the pool & loved being in it, plus my son got an impromptu early morning dip.

I really felt that this had definitely been THE Dress Rehearsal.

Rested during the day again, though couldn't sleep. Cassy came to see me & said she expected me to still be doing the same this time next week. She knew what she was doing – I always like a challenge. So, later that day.....

5.59pm – good contraction – 1 minute long & I have to really concentrate

6.01pm – another good one

6.14pm – good contraction

6.21pm – and another. Here they come again 6.29pm / 6.36pm / 6.44pm / 6.50pm / 6.58pm / 7.08pm / 7.18pm / 7.21pm / 7.28pm / 7.42pm / 7.49pm / 7.56pm / 8.01pm / 8.16pm / 8.25pm / 8.32pm / 8.35pm / 8.40pm / 8.44pm / 8.51pm / 8.56pm / 8.58pm / shall I phone Cassy? Decide not to quite yet / 9.05pm / 9.08pm / 9.13pm / 9.17pm / 9.25pm / Phoned Cassy to let her know what was happening but said I didn't need her yet / 9.37pm / 9.44pm / 9.52pm / 9.57pm / 10.05pm / 10.12pm / Phoned Cassy & dithered about whether ‘this was it' said I didn't need her yet / 10.20pm / worried about Cassy getting here with her hour-long journey / 10.26pm / Phoned Cassy & said I had changed my mind & I did want her to come – she was already sat in the car on her drive about to start the engine / 10.36pm / 10.39pm / 10.43pm / 10.48pm / 10.52pm / 10.54pm / 11.00pm / 11.09pm / 11.12pm / 11.18pm / 11.24pm / 11.32pm / 11.38pm / Natasha, Second On-Call midwife arrived as she was passing (she had been to a gig – she doesn't just roam the streets at that time of night on the off-chance a woman might have a baby) – next few contractions very weak as I'm a sensitive creature who doesn't like being disturbed when in labour. Contractions were so weak I could talk through them / 11.48pm / 11.54pm / 11.59pm / FRIDAY 12.05am / 12.09am / 12.15am / 12.19am / 12.22am / 12.25am / 12.29am.

12.30am - Cassy arrived (got stuck in heavy traffic) & I stopped keeping track of the contractions. Very briefly, after she had checked me over, Cassy left me to it (she knew I needed my own space to make progress so she went to sleep on the sofa bed in the living room. It was good knowing she was just downstairs when I needed her). Things hotted-up. Then my 2 year old got up & had a screaming head-spinning tantrum. I spent a good hour trying to get him back to sleep but failed miserably due to the fact I kept scaring the be-jesus out of him every 5 minutes with a bellowing contraction. My sister came round & took him to the basement playroom to entertain him. Things hotted up again, I got in the pool, my husband fetched Cassy & the baby was eventually born at 5.14am in the pool.

I could tell that when Jayne phoned me the first time that she did want me there, even though she said ‘not-yet' so I decided to just get myself sorted out and go anyway. As it was she phoned me a few minutes later to say she did want me to come, I was already in the car. I had called Natasha earlier in the evening because I knew she was at a gig close by and wanted to give her some warning that I may well call her out later. Usually at that time of night the roads would be quiet - BUT being sods law the motorway was closed overnight to allow repairs to a bridge and all traffic was diverted for miles!! I called Natasha and asked her to go straight to Jayne's house as I was stuck in traffic trying to follow the diversion! A 45 min journey actually took me 2 ½ hours!

I eventually arrived around 12.30 to find a very self contained and calm Jayne having tea in the kitchen with Natasha whose husband was sitting outside in the car. I felt that it was fine for Natasha to go home at this point and knowing Jayne, could also see that she needed space and we were distracting her. After a quick check of Jayne and baby, I went to have a lay down on the sofa and told Jayne to call me when she needed me - of course I wasn't asleep, just waiting. Eventually Jayne's husband called me up and their baby was born (soon after the rupture of bulging INTACT membranes). Natasha had just returned about 15mins before the birth. We made everyone comfortable, had breakfast and left to go home again around 9.30 am.

So, as you can see, the 2/3 nights leading up to the main event were definitely NOT a case of piddling about. They were simply normal parts of a normal labour – a thorough warm-up in preparation, laying the ground for a good efficient labour when the time was right. They were hard work – I was knackered through the lack of sleep before I even got to the Thursday night. But it was all about my body ‘gently' opening the cervix so it wouldn't have to work so hard ‘on the night'.

There are a couple of other observations I had in hindsight which I also wanted to mention.

•  If I hadn't had one-to-one midwifery care & had booked a hospital birth, how different might my experience have been from the onset? What if I had told staff my waters had broken & I refused Vaginal Examinations? Many hospitals have a policy of automatically inducing women if their labours have not begun 24 hours after membranes have ruptured. It is well documented that inducing labour though an intravenous syntocin drip produces more painful contractions than those produced naturally by the body & I would probably have requested an epidural & entered into the slippery slope of high intervention. As it happens, my waters hadn't gone at all – I'd probably experienced that collagen thingy that Cassy explained earlier. How many other women does the collagen thing happen to regularly? I had 1 vaginal examination when I started asking for entonox & Cassy found I was 8cm with bulging membranes intact. I can't help wondering how many women are regularly induced under similar circumstances, when what they're experiencing is a perfectly normal part of labour.

•  How common is it that women who think they're in ‘early labour' are advised to ‘go for a brisk walk to get things going' or other similar exhaustive activities? I know lots of friends have been given this ‘advice' when actually, they were experiencing a normal warm-up labour & should have been resting, sleeping, eating well & conserving their energy. How many women manage to exhaust themselves through endless marching (often encouraged by well-meaning but ultimately misguided supporters) & on-off contractions over days & nights & end up throwing themselves headlong into a high-intervention birth because they've got nothing left in reserve when things really kick-off?

I consider myself to be very lucky that I experienced the gold standard – one-to-one midwifery-led continuity of care. Without this level of care & the wealth of Cassy's experience in normal birth, I doubt I would have had the opportunity to have a completely normal labour & birth in water.

The reason for writing this article was because once I got through the first night of warm-up labour & Cassy told me what was going on, I found it really difficult to find any references to this sort of ‘pre-labour' on the internet. You can find endless checklists about shows, waters breaking etc, but virtually nothing about this type of build-up. In addition, nearly every birth story I've ever read (and believe me, that's quite a few) follows a pattern of ‘the contractions started, I had a labour, the baby was born' .

Very few birth stories, & indeed women, seem to mention the endless days & nights they spent up & down before the main event. So I hope others might find it helpful to learn the following from my own experience;

a) On-off contractions spanning days, nights or even weeks are perfectly normal

b) Your body is doing a lot of really beneficial ground work – unlike me, don't get frustrated or think that your body's useless, just go with the flow. It's not PRE-labour, it's a PART OF labour.

c) Conserve your energy (you're going to need it later) & don't embark on a 5 mile hike in a futile attempt to ‘get things going'.

d) Your waters may not have actually broken. If they haven't, you don't have to worry about going in to labour or the risk of infection. See Ronnie Falcao's resources to double check your signs & symptoms. I thought it was amniotic fluid that splashed on the floor in the bathroom because there was such a large quantity of it that I had to clear up – about half a glass. I had never heard of the collagen thingy - either before the birth or even since. Cassy initially had to take my word for it because even though a vaginal examination (with a speculum) MIGHT have determined whether my waters had broken or not, if they had gone, introducing anything can increase the risk of infection and also give a false positive or a false negative result so would increase my risk without necessarily giving me a definite answer!

e) One-to-One Midwifery-led Continuity-of-Care rocks