​Many women who have experienced childbirth remain puzzled about this elusive entity known commonly as “labour​”. There are also many versions of labouring symptoms and signs contributed by friends and relatives. Among those include back pain, tummy pain, bladder pain, bleeding from vagina, bursting of water bag and constipation-like symptoms. 

No two women may experience the same thing. A woman who has more than one child commonly has different experiences for each of her labour. 

Labour is characterized by: 

  • ​​Painful womb contractions 
  • Progressive dilatation of the neck of the womb (cervix) 
  • Possible rupture of the amniotic membranes with leakage of liquor or passing out of a mucous plug or bloody show. 


Painful Uterine Contractions 

This is a necessary component of labour. Womb contractions that are associated with increasing pain signal the dilation of the cervix and the possible onset of labour. Contractions that are​ not associated with pain are probably “Braxton Hicks” or commonly known as “practice” contractions or false labour pains. These painless contractions do not cause opening of the cervix. 

In the majority of cases, the pain associated with labour is severe; although this may start out as moderate. It is less common that women experience the true labour pains associated with progressive cervical dilation without requesting some form of pain killers​. 

One distinguishing feature of labour pains is that it is episodic. Women describe that the pain/contraction builds up and last for 10–60 seconds, and then subsides spontaneously. This same character of pain returns between 5 minutes and 30 minutes. 

Your labour is considered established when the contraction increases in duration (e.g. commonly lasting at least 30 seconds) and frequency (e.g. occurring every 5–10 minutes). This is associated with opening of the cervix to 3–4 cm. 

Progressive Cervical Dilatation 

A vaginal assessment is necessary to determine the opening of the cervix. This is usually well tolerated by patients except in patients with vaginismus, a condition characterized by the involuntary squeezing of the pelvic muscles upon insertion of the examining fingers. The use of adequate pain relief such as entonox or epidural helps greatly in such cases. 

In addition, staying calm and relaxed in the presence of a supportive partner is also helpful. In modern obstetrics, the husband/partner of the patient stands by her side to support her during such an assessment. The patient lies on her back and​ ​relaxes her thighs to either side. 

Gentle cleansing is done to the exterior. In between contractions, the examiner inserts two digits (that are well lubricated with obstetric cream) gently into the birth canal. Breathing exercises may help in relaxation during this process. If you are allergic to the cream that is commonly used, alternative solutions may be used. 

The examiner is able to assess your labour by determining the opening of the cervix in centimeters, the texture (soft or firm), position (front or back), station (head is low or high), and effacement (thin or thick). Established labour is associated with wider opening, soft texture, front position, thin cervix and low head. There is a need to re-examine you again a few hours later to confirm that your cervix is dilating and that your labour is progressing normally. The cervix is considered fully dilated when the opening is 10 cm. 


Additional signs of labour 

Rupture of your membranes will present as “a gush of warm straw-colored fluid” between your legs. This can be distinguished from urine as it will feel warm and smell sweetish, unlike the strong ammonia smell of urine. 

If your baby has passed motion, the fluid will be yellowish or greenish instead. This leakage tends to be continuous till your baby delivers. Once this happens, you must head for the hospital regardless of the presence of the other symptoms. 

About 80% of women with ruptured membranes will go into established labour pains within 24 hours of the event. 90% of women will go into established labour within 48 hours. 

The mucous plug is a gelatinous substance that covers the opening of your womb in pregnancy. Passing out of this plug may herald the onset of labour proper, but it may take hours or days before labour actually starts. Bloody show presents itself as a mucoid discharge that is tinged brownish. Like the mucous plug, it may be a sign that the cervix is dilating and labour is about to begin soon. 

There is no time line to deliver the baby after experiencing a show or mucous plug. The pre-requisites of painful uterine contractions associated with progressive cervical dilation must be present for established labour. 

Pain in the uterus that is continuous and severe without respite may indicate premature separation of the placenta from the uterus (abruption placenta). This is a serious condition that requires immediate access to hospital. This condition is also associated with fresh red vaginal bleeding (unlike bloody show) and unrelenting pain. One reason why labour remains elusive is that the trigger and sustenance are unpredictable.​ 

Some scenarios commonly encountered in the delivery suite 

1. A patient describes having painful contractions for about 10–​15 seconds that occur every 30 minutes. The pain settles down and she is in no pain after about 4 hours. A vaginal examination showed that the cervix is closed. 

Doctor's comment: This is a common scenario seen in maternity hospitals. As the cervix is closed despite the description of painful contractions earlier, the patient is not in labour. The contractions were not sufficient to cause opening of the cervix (i.e. no work is done despite the pain). Painful contractions may subside and may not recur even after many days. 

2. A patient describes having painful uterine contractions for 30 seconds that lasts every 10 minutes. A vaginal examination showed that the cervix is 2 cm dilated. 

Doctor's comment: This patient is in “early labour”. The painful contractions had resulted in some “work done” as reflected in the opening of the cervix to 2 cm. However, even at this stage, the contractions may subside resulting in no further natural progress. Some of these patients opt to go home after being monitored during the contraction phase in hospital. Others may opt for induction of labour. 

3. A patient describes having painful uterine contractions for 30 seconds that lasts every five minutes and appears to be getting closer. A vaginal examination showed that the cervix is 4 cm dilated. 

Doctor's comment: This patient has painful, regular contractions that persist and the cervix is opening. She is in established labour.​ 

Premature Labour (i.e. < 37 Completed Weeks of Pregnancy) 

Some women experience premature labour pains. The character is similar to normal labour pains. Premature labour is commonly more rapid and may result in the expulsion of the baby soon after labour begins. Hence, many doctors are cautious in evaluating pain in the second and early third trimester to identify premature labour pains and to arrest it early. 

Women who experience possible labour pains before 36 weeks gestation should consult their obstetrician promptly. 

What if I Cannot Get to the Hospital on Time? 

Most of the time, our patients are able to seek medical attention before the baby delivers. Occasionally, we still do have mothers who deliver before they can reach the hospital. Such an occurrence is more common in those who have delivered before and labour pains may be mistaken for insignificant abdominal cramps. 

It is also more common in those with a history of rapid labour or precipitous labour, whereby the baby delivers within a few hours of the onset of labour. 

Should this ever happen to you, the following is a suggested guide on what should be done (see Figure 32.4): 

  • ​​​Remain calm at all times. The last thing you and your partner should do is to panic. 
  • Call for help. This includes dialing for the ambulance (995) and alerting your neighbours or someone to come and assist you. 
  • Prepare for your delivery: 
    • ​a. Lie down on a bed or sofa while awaiting medical help. 
    • b. Spread some clean towels under yourself. 
    • c. If possible, your partner should wash his hands and your vaginal area. 
    • d. Avoid pushing as this may expedite the delivery. In times like this, deep breathing may help distract you. 
  • ​​Delivering your baby: 
    • ​​a. Should you or your partner start to see the baby’s head, then you should help by pushing each time you feel the urge to bear down. 
    • b. Let the head emerge on its own. Never attempt to pull it out and should there be a loop of umbilical cord around the neck, you or your partner should gently hook it over the baby’s head. 
    • c. Once the head is delivered, hold it gently with two hands and press it downwards so that the anterior shoulder can be delivered under your pelvic bones. 
    • d. Once the anterior shoulder is delivered, you may gently lift the head so that the posterior shoulder can be freed.​ ​
  • After your delivery: 
    • ​​​​a. Keep the baby warm by wrapping him/her in a clean towel, before placing it on your abdomen. 
    • b. Do not attempt to cut or pull onto the umbilical cord. 
    • c. Should the placenta deliver spontaneously, manually rub the uterus by placing your hands onto the lower part of your abdomen. This will promote the contraction of your womb and reduces the blood loss. 
    • d. Make yourself comfortable while help is on its way.​ 



Acknowledgement

Source: Dr TAN Thiam Chye, Dr TAN Kim Teng, Dr TAN Heng Hao, Dr TEE Chee Seng John, The New Art and Science of Pregnancy and Childbirth, World Scientific 2008.

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