When to go to hospital...

[redpajama]

I'm a doula and I have clients who wish to labor at home "as long as possible" (I don't think they mean this literally) before going to the hospital for their birth. They are doing this primarily to avoid unnecessary intervention.
They asked me when they "should" go to the hospital, and I wasn't exactly sure what to tell them. On one hand, transition is usually pretty easy to observe externally (no one will be performing internal exams), and it's far enough along that they won't be sitting around refusing epidurals and starving themselves...but, in my experience, there's enough "transition" taking place as it is, and one might not need the additional transitions from house to car to hospital during that time. It seems to me that it might serve to really interupt their rhythm at a time when they really need to be able to maintain their calm and focus. I didn't like being spoken to during transition, and I would hate to see them put through all the obligatory admission questions, et cetera, during that time. On the other hand, I don't want them getting there so early that they are subject to a long hospital labor and all the unwanted intervention that can ensue.
I guess I'm asking opinions on what you think might have the lowest impact on their labor. Would it be better to stay home longer, even if it means travelling during transition, or would it be better to try to get to the hospital before transition, and run the risk of getting there *too* long before transition?
Thoughts?

[sweeetpea]

I think this is a necessary discussion to have with the parents during your prenatal meetings. Clarify what their idea of "as long as possible" is. It can vary from "When I can't take the pain anymore" to "I want to push the baby out in the elevator"

If it is their first birth, be clear about what transitioning in transition may feel like. Much may depend on the length of the car ride! My opinion is that, in general, those who want to labor at home as long as possible would be best served having a home birth : , but short of that, going to the hospital as close to pushing as possible, even if it means an uncomfortable car ride and hike through the hospital corridors.

When in labor, if a mom asks me "Do you think it is time to go?", it generally is not time yet. When a mom says "I think it is time to go", it is more likely to be time, although I still ask her why she thinks it is time (if she just wants a change of scenery or if she really does sense birth is close). Using emotional and physical signpost information is generally as informative (or more) than cervical dilation.

This is one of the reasons why home births are soooooooo much more laid back. There is no mental stress of "when should we go and how is the traffic?"

Sweetpea

[SublimeBirthGirl]

If I were going to have a hospital birth, I'd leave when I started pushing. Seriously. I agree that they should evaluate why they're going to the hospital at all.

[nimblemama]

There is not a magic answer of when to go to the hospital or birth center. Both of my births were in birth centers, so I had about a 25-minute drive. We left when I "felt" like I needed to. I had labored awhile at home (7 hours for 1st birth and 6 for the 2nd). When I got to the center, I was dilated at 4/5 both times. I gave birth 4 hours after arriving with my first and 2.5 hours after arriving with the second.

I knew to leave when my contractions were becoming harder to work with and I wanted to be with the midwife at the center. Plus, with the first, I started throwing up at home, but was not quite to transition yet.

[MidwifeErika]

I would have them read some books on what normal, unmedicated labor looks like and then have them decide at what point they would like to go in. I have to say, I discourage people from rushing in if the mom is pushing or the baby is crowning, I think at that point it is safer to stay at home to catch a baby rather than birth in a car going 100mph with a frantic dad trying to drive at the same time. This is something I tell people during the prenatal meetings, that if they are so relaxed at home that a baby starts to come out, it is much safer to call 911 and just have that baby at home and go in afterwards (if they feel that a hospital trip is needed).... I would never try to get people to stay at home that long (just a disclaimer), but if it happens, it happens.

Really, you will be able to help them gauge it. A mom who is still gigglinig through contractions and barely cringing at the peak, most likely has some work to do yet. A mom who needs the world to stop for her during contractions and is starting to complain about nausea and sweating is probably much closer.

[AmieV]

When you figure it out, let me know! My first birth, it really seemed like it was time to go (birth center). Ctx were close, hard, and I was really working through them and having a hard time recovering. But once we got there, everything shut down. And I was totally cool, happy and comfortable being there (too cool?). ctx went to 8 minutes apart and barely doing anything. So the midwife sent me home. My water broke on the way back home, things got crazy at home after that (a couple of hours of really intense labor), my mom made the call that it was time that it was time to go back. Horrible painful car ride, baby born an hour and a half after we got there.

I think it's worth discussing how they feel about the hospital, why they want to get there late, etc. And like others have said, how close are they talking, how close to "baby in the elevator" scenario. For me, I really liked my birth center and had been looking forward to using all the goodies there. I did get to use the birth ball and get in the tub for a bit, but I could have been there sooner and been comfortable. Then again, my labor didn't progress there so maybe I wasn't as comfy as I thought.

I haven't been in the position to be a labor support person (yet!) but since I'm so clueless on my own labors I'd have a hard time advising someone else. Even with my homebirth...I jumped the gun so much the first time around that I guess I didn't believe it was the real deal and that time it was my husband who made the call to get the midwife over, baby born a few hours later. I didn't even believe I was in active labor! Not sure if that kind of crap intuition is standard though. Maybe your clients are better at that than me.

fwiw, I think labor in the car sucks in general, not sure if transition would be all that much worse. I mean, it sucks, or it REALLY sucks, right?

[BirthFree]

There's the general 4-1-1 rule (ctx 4 min. from start to start, lasting a full minute for an hour) but I've seen people do that and still not be far along, and others do 30 sec. ctx 3 min. apart and be 8cm.

Myself, I usually follow Mom's lead on when we should go (since it is indeed her choice) but if we are going too early and they want to stay home as long as possible, I may point out they are still smiling, thinking their DH/partner is funny, etc. But I've been at the hospital the past 4x at 8cm - each time their ctx. were closer than the 4-1-1 though not lasting a minute. It still took hours and hours before baby was born - so I am thinking laboring at home could be drawn out further as the comfort of the family determines.

I have found that emotional signposts are so much more reliable - numbers are just numbers but emotions show usually.

[DoomaYula]

Yeah, LMK too! Esp for primips!

Recently I had a client who wanted to stay home as long as possible... she was throwing up, she couldn't talk between ctx, she was getting really "spacey," and she felt it was time. I was CERTAIN she was probably at at least 4 or 5cm. (Did NOT say that out loud, thankfully!)

We got to the hospital and she was barely at 1cm! :

However, imo, just the experience of walking into the hospital practically shut down her labor. She went from having ctx every 2m to every 8m and they shortened and weren't so painful.

It took FOREVER before she got back into a good rhythm. She got back in her own clothes, we did some relaxation, her dh was very supportive, but it took at least 90 min before her ctx got going again.

[gemasita]

YumaDoula - I've had experiences like yours so I think now I don't trust myself. I've just seen a lot of labors that don't seem to fit the "pattern." The first birth I attended as a doula was a precipitous birth so maybe that what has caused me to mistrust myself.

[Inner_Serenity]

In regards to when a client should go in, I first evaluate their desires and try to find common language so there is no misrepresentation.

I next ask them to share their desires with their caregiver, Midwife/Dr. This usually starts a dialogue on what the caregiver and client feel comfortable with...

It is not truly my call when my client should or should not go to the hospital but instead to support them when they desire to go... As just a Doula I am not collecting all of the pertinent information that would be important to make this call...

A Mother can always leave the hospital and return home, if her labor is not well initiated... But if she needs to go, she needs to go

I just had a birth that seemed to be moving along perfectly, we left for hospital at 4 minutes apart regular for 2 hours... When we arrived and did initial assessments she was only 1.5 cm, but also had serious complications as she was in full blown HELLP Syndrome. Her blood work came back with serious levels and her BP was elevated... SO in the long run my mom's instincts that it was time to go to the hospital were correct...

Tia

[Jane]

I think that no one should aim to go to the hospital when their labor is still stoppable. Once things are rolling along, the mom has stopped watching the clock, and is in labor land, and doesn't pay attention to all the stupid stuff that has to happen at check in...it's okay to go. I think the 5-1-1 rule works well for primips. To that, I add things like, it's taking the mom's full attention for the whole contraction, she has some quiet time between to catch up for the next one, even.
It's easy in retrospect. When a mama doesn't remember what floor she went to, and that the nurse who checked her in wore pink and purple pyschedelic scrubs...it was an okay time. When she remembers the number of the parking space they parked in...it was too soon.

[DoomaYula]

Originally Posted by Inner_Serenity

A Mother can always leave the hospital and return home, if her labor is not well initiated...

Not at my local hospital; it's like trying to leave a cult. Even when I had a client who wasn't admitted, she was not "allowed" to leave, and I was separated from her while she was in triage for 2h.

If a client wants to stay home, I encourage her to stay home as long as possible, because once she's in, she's in.