Just Say “No” to Hospital Admission in Early Labor

If this is your first baby, unless you have a medical condition that warrants closer monitoring, you don’t want to be in the hospital until you are in active labor.

Let’s look at why admission in early labor could theoretically be a problem and the evidence supporting that, in fact, it is one. Then, as I usually do, we’ll wrap up with some practical suggestions on what you can do about it.

What’s the Problem with Hospital Admission in Early Labor?

The potential problem with early hospital admission is that for several—sometimes many—hours after labor begins, cervical dilation tends to proceed at a leisurely pace (pre-active labor). At a certain point, usually around 6 cm cervical dilation, or a little more than halfway through the journey to full dilation at 10 cm, the labor shifts into higher gear and progress becomes more rapid (active labor).²

Many doctors, however, believe that this shift occurs earlier in the dilation process than it typically does. The expectation that dilation should be proceeding faster than it normally does in this phase of labor may lead them to an unwarranted diagnosis of “failure to progress” and to unnecessary medical intervention based on their perception.

What Evidence Do We Have for This?

Establishing the validity of this theory involves answering three research questions:

1. Does admission in pre-active labor increase the percentage of first-time mothers deemed to be making inadequate progress and who are treated for that perceived problem?
2. Does admission in pre-active labor increase the probability of cesarean surgery and instrumental vaginal delivery in first-time mothers?
3. Could there be an alternative explanation for an association between hospital admission in early labor and increased use of medical intervention and surgical or instrumental vaginal delivery?

Let’s take these one at a time and see what the research finds.

Does admission in pre-active labor increase the percentage of first-time mothers deemed to be making inadequate progress and who are treated for that perceived problem?

The research finds that it does. Compared with women further along in labor, first-time mothers admitted in early labor are more likely to be diagnosed as having progress delay.^{3, 10} With admission later in labor, 16 to 43 fewer per 100 will be given IV oxytocin to intensify (augment) their contractions in an attempt to speed up progress.^{3, 5, 6, 9, 12-15}

Does admission in pre-active labor increase the probability of cesarean surgery and instrumental vaginal delivery in first-time mothers?

The money question is whether the expectation that labor should be proceeding more rapidly influences decisions about mode of delivery. Cesarean surgery and instrumental vaginal delivery should be avoided whenever unaided vaginal birth can be safely accomplished because while beneficial under some circumstances, both can have serious adverse effects.

With respect to cesareans, the answer is “yes.” Studies consistently find increased incidence of cesarean surgery in first-time mothers with earlier admission in labor. Studies report anywhere from 3 to 11 fewer first-time mothers per 100 with later admission having cesareans.^{3-5, 7-9, 13-16} Even more to the point, they report 4 to 8 fewer cesareans for progress delay.^{6, 14, 15} In addition, a couple of studies have found that degree of cervical dilation at hospital admission correlates with probability of cesarean.^{6, 8}

With respect to instrumental vaginal delivery, studies disagree. Some find that admission in pre-active labor increases instrumental vaginal delivery rates,^{7, 14} while others report similar rates.^{3, 5, 9, 15} The two finding an effect reported 2 and 12 fewer instrumental deliveries per 100 with later admission.

Could there be an alternative explanation for an association between hospital admission in early labor and increased use of medical intervention and surgical or instrumental vaginal delivery?

It is possible that women admitted in early labor come to the hospital sooner because they are experiencing more painful, difficult labors. Women having difficult labors would be more likely to need medical intervention to try to speed progress and to have their labors end in cesarean or instrumental vaginal delivery.

The studies suggest, though, that this doesn’t explain the difference. While difficult labor may be the reason why some women present at the hospital early in labor, studies report that half or more of their participants were admitted to the hospital in pre-active labor.^{1, 3-8, 10, 13-16} It seems unlikely that such a high proportion of women overall would experience difficult labor. Much more likely is that admission in pre-active labor is common and that these women are being managed according to what would be expected of women in active labor.

The American College of Obstetricians & Gynecologists and the Society for Maternal & Fetal Medicine agree with this explanation. Here’s what they say in their joint consensus statement on preventing first cesareans:²

“Cervical dilation of 6 cm should be considered the threshold for the active phase of most women in labor. Thus, before 6 cm of dilation is achieved, standards of active phase progress should not be applied.”

ACOG/SMFM Obstetric Care Consensus
Safe Prevention of the Primary Cesarean Delivery

Your Take-Away

This brings us to what you can do about this. That, in turn, depends on whether you are free to choose when to go to the hospital or whether other factors—your health, your distance from the hospital, the weather—influence that decision. Let’s address the two possibilities.

How can I ensure that I’m admitted in active labor?

• Hire a doula. Doulas have skills and knowledge to help you be comfortable at home.
• Take a set of childbirth preparation classes. Knowing what to expect and having strategies to cope with labor can help you and your partner time your hospital admission appropriately.
• Wait for at least an hour and probably more of strong, regular contractions before heading to the hospital. As a rule of thumb, you’re looking for contractions that occur no more than 5 minutes apart counting from the beginning of one contraction to the beginning of the next, last about a minute, and are strong enough that you can’t walk or talk while you’re having one.
• Ask to be checked when you arrive at the hospital and decline hospital admission unless you are at least 4 cm dilated and have a strong, regular contraction pattern. (See previous bullet.) If you’re still in early labor, return home. If you’re feeling that things might be picking up, hang around the hospital or somewhere close by for an hour or so and then go back and get rechecked. If there hasn’t been a change, again, go home.

What if there are reasons why I need to be at the hospital sooner rather than later?  

• Hire a doula. She can provide ongoing one-on-one physical and emotional support to you and assistance and emotional support to your partner.
• Take a set of childbirth preparation classes. As with labor at home, knowing what to expect and having strategies for coping with labor will help you and your partner feel confident and in charge.
• If an epidural is your plan, delay it until active labor. Moving around and staying active helps labor progress.¹¹ Again, a doula and knowing comfort strategies and techniques can help you delay an epidural. You may even find you don’t feel the need for one.
• Have patience. Time is your friend, and impatience is your enemy.
• When you are checked, get all the information. Hearing that dilation hasn’t changed can be discouraging and misleading. Other changes—the cervix softening and shortening (effacing), the cervix moving forward to line up with the birth canal, and the baby’s head moving lower in the pelvis—are also progress and may have to occur before dilation starts to accelerate.

References

1. World Health Organization partograph in management of labour. World Health Organization Maternal Health and Safe Motherhood Programme. Lancet 1994;343(8910):1399-404.
2. American College of Obstetricians & Gynecologists, Society for Maternal-Fetal Medicine, Caughey AB, et al. Safe prevention of the primary cesarean delivery. Am J Obstet Gynecol 2014;210(3):179-93.
3. Bailit JL, Dierker L, Blanchard MH, et al. Outcomes of women presenting in active versus latent phase of spontaneous labor. Obstet Gynecol 2005;105(1):77-9.
4. Davey MA, McLachlan HL, Forster D, et al. Influence of timing of admission in labour and management of labour on method of birth: results from a randomised controlled trial of caseload midwifery (COSMOS trial). Midwifery 2013;29(12):1297-302.
5. Holmes P, Oppenheimer LW, Wen SW. The relationship between cervical dilatation at initial presentation in labour and subsequent intervention. BJOG 2001;108(11):1120-4.
6. Iobst SE, Breman RB, Bingham D, et al. Associations among cervical dilatation at admission, intrapartum care, and birth mode in low-risk, nulliparous women. Birth 2019;46(2):253-61.
7. Jackson DJ, Lang JM, Ecker J, et al. Impact of collaborative management and early admission in labor on method of delivery. J Obstet Gynecol Neonatal Nurs 2003;32(2):147-57; discussion 58-60.
8. Janssen PA, Stienen JJ, Brant R, et al. A Predictive Model for Cesarean Among Low-Risk Nulliparous Women in Spontaneous Labor at Hospital Admission. Birth 2017;44(1):21-8.
9. Kauffman E, Souter VL, Katon JG, et al. Cervical Dilation on Admission in Term Spontaneous Labor and Maternal and Newborn Outcomes. Obstet Gynecol 2016;127(3):481-8.
10. Kjaergaard H, Olsen J, Ottesen B, et al. Obstetric risk indicators for labour dystocia in nulliparous women: a multi-centre cohort study. BMC Pregnancy Childbirth 2008;8:45.
11. Lawrence A, Lewis L, Hofmeyr GJ, et al. Maternal positions and mobility during first stage labour. Cochrane Database Syst Rev 2013;10:CD003934.
12. McNiven PS, Williams JI, Hodnett E, et al. An early labor assessment program: a randomized, controlled trial. Birth 1998;25(1):5-10.
13. Neal JL, Lamp JM, Buck JS, et al. Outcomes of nulliparous women with spontaneous labor onset admitted to hospitals in preactive versus active labor. J Midwifery Womens Health 2014;59(1):28-34.
14. Neal JL, Lowe NK, Caughey AB, et al. Applying a physiologic partograph to Consortium on Safe Labor data to identify opportunities for safely decreasing cesarean births among nulliparous women. Birth 2018;45(4):358-67.
15. Neal JL, Lowe NK, Phillippi JC, et al. Likelihood of cesarean delivery after applying leading active labor diagnostic guidelines. Birth 2017;44(2):128-36.
16. Wood AM, Frey HA, Tuuli MG, et al. Optimal Admission Cervical Dilation in Spontaneously Laboring Women. Am J Perinatol 2016;33(2):188-94.