When to go to the hospital?

I have been teaching prenatal classes for almost ten years. Currently I teach a prenatal class at St. Michael's Hospital in downtown Toronto. During introductions I always ask the students, what the one thing is that they want to know before they leave the class. In each class over 50% always ask, "When do we go to the hospital?" I know when I was pregnant that's the one major topic I wanted information on. So lets discuss that. Please keep in mind though that this is not medical information. This is mainly a recommendation and you will need to take into account your own medical history and the recommendations of your doctor or midwife.

We first need to consider what labour might feel like. The steps leading up to True Labour may include:

The loss of your mucous plug. Which can happen days to weeks before your labour actually begins. The mucous plug corks the cervix. When it comes out it may been tinged with red or pink as the cervix begins its initial thinning and dilating. If this is your first labour and you notice your mucous plug, it doesn't mean labour is starting or imminent. First labours may not start for several days or weeks after the loss of the mucous plug. Listen to your body but have lots of patience, if you have lost your plug you may still be pregnant next week.
Increased Braxton Hicks activity. The pre-labour contractions that are your body's way of practicing for the big day. Your body doesn't go from couch potato to marathon runner over night. It has to train and Braxton Hicks contractions are the training. They will become more frequent and possibly more uncomfortable.
Lightening. Which is when your baby "drops" further down into the pelvis. Giving you the ability to breathe easier and eat larger amounts as you now have more space in your upper abdomen. Sadly though you will be peeing even more frequently as your baby's head presses down on your bladder.
You may feel like your period is coming on. Mild cramping in the low back and lower abdomen.
You may feel like you are getting the flu. Some women will experience nausea and fatigue as the body begins to release Oxytocin into your system.

These pre-labour steps are not cut in stone though. You may feel all of them, some of them or none of them. For first time labours these signs could start days to weeks before true labour begins.

Eventually the Braxton Hicks you may be feeling will change in feeling and intensity. True labour is starting. You will want to keep an eye on these and time a few of them. They will be mild at first. You should be able to walk and talk through them. They will be short in length, lasting approximately 30 seconds long. And they will be spaced sporadically apart. Eventually they will become Longer, Stronger and Closer together.

Of course you will also need to know how to time a contraction. There are apps for this if you wish to use one but I caution you to not be reliant on technology. The old school method is basically this...

When a contraction starts, using a watch or a clock/timer on your phone, you or your support person will write down the time. Then when the contraction stops you write down the time. The difference between those two times gives you the length of the contraction. When the next contraction starts you write down the new time. When your care provider wants to know how far apart your contractions are, they are looking for the difference between the beginning of one contraction and the beginning of the next.

Given the example above, if the duration of the contraction is 60 seconds and there is 2 minutes between the stop of one contraction and the beginning of the next, this would be a 3 minute contraction. Make sense? Clear as mud right?

So we come to the crux of this post. When do you go to the hospital? You will want to check with your local hospital but if you are in Toronto, a majority of hospitals are looking for you to come in when your contractions are 3-4 minutes apart, lasting about a minute and you've had an hour of those. Try to remember 3-1-1. (Like the example above)

In theory, this should put you at about 5 cms dilation, which is about when active labour is starting. Most hospitals now, for low risk, first time labours will not admit you until you are in active labour unless there is a medical reason to, even if you want an epidural. If you are not 5-6cms dilated you maybe sent home or for a walk around the unit depending on how dilated you are. This is in an effort to lower the cesarean section rate, which in Toronto is close to 30%. We know that getting to the hospital early doesn't get you a baby any sooner. It may however get you multiple interventions which can possibly cascade to a cesarean section. So if you are well and comfortable at home, stay there.

Now, having said all this, there may be reasons why you will need to come to the hospital earlier. Those reasons may be:

If you have been diagnosed GBS positive. If that is the case your Doctor may want you at the hospital sooner to administer IV antibiotics, especially if your waters have broken at home.
If you do not live close to the hospital. Many times people will chose a downtown hospital because it is convenient for doctor appointments during their pregnancy as they work downtown. That may not be convenient though if you are in active labour and live an hour away and its the morning rush hour. Choose your birthing location carefully.
If you have a medical issue that may require closer monitoring. Your care provider will discuss this with you prior to going into labour so you can plan accordingly.
And finally, if the one who is in labour says they need to go to the hospital, you go. I encourage you to listen to your body and follow your instincts. A few times I've had clients say they need to go and while they didn't fit the criteria stated above, their instincts told them to go and they were either fully dilated or very close to the end when they arrived at the hospital. (I always listen to my client and go with their gut) These are called precipitous labours and while not common (less than 5% of labours are under three hours) can occur and you need to just listen to the one in labour and not look at your phone and say, "But the app says..." Just put everyone in the car and come. Better to be at the hospital too soon than delivering baby on the side of the highway.

So now armed with all this information, sit back and enjoy your early labour at home with your own food, bath tub and comfy bed. Don't rush to the hospital unless you really need to be there. And if you are concerned about labour at all, we encourage you to seek out a Doula to support you in your journey.