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How to Know You're in Labor and the 5-1-1 Rule: Tips from a Doula

Written By
Jessalyn Ballerano
Certified Childbirth Educator & Doula

Confused about early labor, stages of labor, active labor, or even supposed “false labor”? Understanding labor contractions and labor patterns is one way to know if you are in labor, when to seek care, and how to support your comfort and safety in birth.

You may be full of anticipation about when your labor will start and what it will feel like. The 5-1-1 rule is one tool for assessing the difference between warm up contractions and actual labor contractions, and when to contact your prenatal health care provider or birth location.

What is a Contraction?

  • The mechanism
  • The feeling
  • What helps?

Braxton Hicks 

  • Warm-up contractions
  • Braxton-Hicks v. prodromal labor

Labor Contractions

  • Stages of labor
  • How to time a contraction
  • Labor timing tips

The 5-1-1 Rule

  • How to use it
  • Other signs of labor progress
  • When to call your medical provider

What is a Contraction?

When a laboring person is working hard, it’s because their uterus is working hard! That work is called a contraction, and while we associate contractions with labor, contractions are actually a part of life for anyone with a uterus. Here we describe the basics of contractions for a pregnant or laboring person.

The mechanism

The uterus is an incredible muscular organ that is influenced by hormones and a person’s life cycle of reproductive activity. It is usually quite small and shaped like an upside-down pear - during pregnancy it becomes much larger - and stronger - to protect a growing fetus and eventually move them out of the womb and into the world. In fact, the uterine strength it takes to birth a baby makes it one of the strongest parts of human anatomy!

The wall of the uterus is made up of three layers of muscular fibers - an outer layer whose muscle fibers run longitudinally (up and down), and two inner layers in which the muscle fibers run circularly and obliquely. A contraction is when these muscle fibers squeeze in a dynamic action, exerting force like when you “make a muscle” with your bicep and it bulges out - a differences that the uterus has something precious inside of it, and the three layers squeezing in harmony create a few effects along with the hormones of labor:

  • The cervix, the lowest section of the uterus that extends to the vagina, starts to get shorter and soften enough to start dilating, or opening. This is called effacement.
  • As labor progresses the muscular bulk of the uterus starts to consolidate in the upper segment of the uterus. Sort of in the way an octopus can change its shape and thickness, this amazing skill of the human body means that more of uterus’ muscular force will be available to push the baby down and out when it’s time to push.
  • The squeezing muscles cocooning the fetus help them to descend lower in the womb and rotate position to fit through the angles of the bony pelvis.

Contractions are initiated by a chemical interaction that happens at a cellular level in the muscle fibers of the uterus, between a hormone called oxytocin and calcium. The interaction causes the muscles fibers to twitch, or squeeze. As labor progresses, a feedback loop is created in which oxytocin is released, a contraction occurs, the contraction squeezes the uterus and the fetus, creating more pressure on the cervix, which in turn signals the release of more oxytocin, and the cycle repeats itself. This self-sustaining process is called the Ferguson reflex.

The feeling

In labor, contractions are quite strong, but people actually have contractions at other times in life too. This is because the uterus is hormonally regulated, and the hormone that primarily causes labor contractions - oxytocin - is also released when someone orgasms, or during the cramping some people experience during their period. 

In this way, the uterus is contracting at various levels of intensity and muscular engagement throughout someone’s reproductive life. The way this feels will vary greatly from person to person depending on their sensitivity level and tolerance for sensation and pain, existing muscle or postural tension in their body, and the movement, touch or other care they receive while experiencing the contraction.

Common descriptions of spontaneous (non-medicated) contractions include:

  • Waves of intensity, may or may not be painful
  • A deep ache that rises and fades, starting out dull but getting stronger
  • A tightening and squeezing sensation in the lower back or abdomen
  • Pressure at the pelvis and vagina, sometimes with pain sometimes not

It is important to note that contractions induced by medication or synthetic oxytocin are often reported to be much stronger and more painful. This makes sense - the synthetic hormone may be released in intervals or dosage amounts much higher than a person’s natural labor rhythm. Medicated/induced contractions may be intense enough that someone who was not intending to use any medications opts for pharmaceutical pain relief.

What helps?

Depending on how contractions feel for someone, they may want some help coping with the physical sensation. Not everyone describes contractions as painful, but almost everyone describes them as very intense, and some of the ways we manage labor and delivery in the United States might influence a person’s experience of the sensation. For example, if you are feeling a lack of support or are frightened by something a medical person said, you might tense up and experience more pain than if a trusted person rubs your back, helps you breathe through it, or the staff person communicates in a calm, reassuring way.

The hormone mentioned above, oxytocin, is responsible for the muscular dynamic of contractions, but it also acts as a neurotransmitter in the brain, responsible for the feelings of attachment, trust, bonding and love that we feel with our dear ones. Activities that boost natural oxytocin can, along with helping labor to progress, create a sense of calm and safety, lower cortisol levels, and support the release of natural painkillers called endorphins. Many of these activities also serve to distract or soothe from the intensity of labor contractions.

  • Changing positions regularly to shift with the changing pressure 
  • Movement using rhythm, like walking, swaying on a birth ball, dancing
  • Comforting touch that feels soothing to the individual or provides counter-pressure
  • Deep, full breaths in your natural rhythm that help the laboring person and their baby to stay oxygenated and circulating blood
  • Soft, open sounds, like “oooohs” and “aaaaahs” or sighs, that feel good to make and keep your jaw/mouth relaxed
  • Eye contact and presence from a trusted person who is encouraging and calm
  • Verbal encouragement, affirmation and emotional support
  • Resting and eating during breaks or when it feels possible to do so comfortably, to sustain and rejuvenate energy as well as hormonal flow

Other ways someone might manage the intensity of contraction sensation are with medications and some other clinical tools. Most of these have contraindications and some risk to either the laboring person, the baby or both, so be sure to thoroughly discuss any medical interventions with your health care care provider.

  • TENS machine, which sends tiny pulse of electricity to a muscle group 
  • Short-acting temporary narcotic pain relief like morphine or fentanyl
  • Short-acting temporary use of nitrous oxide, which has a relaxing effect on some people, but is not explicitly a pain relief medication
  • Use of an epidural to numb sensation from the chest to the feet 

Braxton Hicks

You may have heard of Braxton Hicks contractions or experienced them in your pregnancy long before labor started. Warm-up contractions that precede labor and labor contractions can be a little hard to distinguish, but they are different - here’s how!

Warm-up Contractions

The mechanism of a uterine contraction is, in essence, a muscular activity. And just like with the other muscles of the body, they need to be used regularly to function well and perform tasks like heavy lifting, walking, or even sitting up with optimal posture for core and back strength. A warm-up or Braxton Hicks contraction can happen long before labor starts, and is just what it sounds like - a warm up of the muscles of the uterus. 

The uterus, or sections of it, “warm up” with squeezes that are sometimes felt across the whole area, and other times just in sections. You can think of it as all those complex muscle fibers tuning and practicing so that when they all work together, they will be effective. Muscular activity on the uterus may also increase as more cellular receptor sites for oxytocin are established as pregnancy continues. Many people describe Braxton Hicks as coming and going, having maybe just a few in the morning or at night, or one every few hours through the day. People describe a tightening across the belly that fades, or the pressure or ache as described above. Usually Braxton Hicks are mild, and they do not establish a regular or sustained rhythm of frequency. 

Braxton Hicks v. Prodromal Labor

As someone approaches their due date, whether or not they experienced Braxton-Hicks contractions earlier in their pregnancy, they may have contractions that start and stop and feel stronger than Braxton Hicks contractions. Some people never experience either, and that’s okay too! These new contractions may be the very earliest signs of labor, and are sometimes referred to as ‘prodromal labor’ if it is suspected that the contractions aren’t causing much change to the cervix. It is sometimes called “false labor” but this is a poor description as the impact of these early contractions varies - it might be better described as “early EARLY labor”! 

A major difference from Braxton-Hicks is that prodromal labor contractions will likely be stronger, and may start to come closer together or establish a rhythm. These contractions may go on for some hours and then cease, perhaps increasing in intensity at certain times of day or fading completely with activities like eating, walking, sleeping. There may also be less sporadic in where they are felt, as the whole uterus is more engaged than during the “warm-ups” of before. 

This pattern may occur over a few days, and while prodromal labor isn’t necessarily a problem, it can be tiring if it goes on for a long time. If it goes on for long enough that it is exhausting someone or if other signs indicate that labor is not starting on its own, someone might decide with their medical care provider to consider induction options. Some ways to manage the mental and physical energy this requires include:

  • Prioritizing rest and nourishment to sustain your energy and give you plenty to burn when labor does start
  • Try not to worry about whether its labor - this takes up your energy and if it’s causing you stress, could actually counteract progress on a hormonal level
  • Surround yourself with supportive, loving people and do things that help you to feel relaxed, which in turn can help your body move towards actual labor
  • Without wearing yourself out, try gentle movements that engage the pelvis, like walking, hiking, dancing, or stretching
  • Know that whether it’s a warm-up or the beginning of labor, your body and your baby are communicating and there will be a change that helps you decide your next steps.

Labor Contractions

Once labor contractions do commence, they are dynamic and will change over the course of labor. Timing contractions can therefore be one helpful indicator of labor progress. Read on to understand the basics of the stages of labor and how to time a contraction pattern.

Stages of labor

Medical terminology for the stages of labor can be very detailed - but you don’t have to understand the exact mechanisms of each part of the process to be able to distinguish between them and the contraction patterns typical to each stage. The simplest way to break it down is by contraction pattern, but cervical effacement, dilation, and the baby’s activity are all considered in assessing labor’s progress towards birth. 

Overall, you can think of labor as a process that gradually builds in intensity and peaks with childbirth. A contraction pattern, the status of the cervix, how the person is feeling, and what the baby is doing will all shape a person’s experience, but here are some common elements for early labor, active labor and transition, and pushing and birth

Early Labor 

As described above, stronger, fuller contractions that start to establish a pattern are what distinguish labor contractions from warm-up Braxton-Hicks. Early labor can feel similar to the prodromal labor described above, but with increasing frequency. Early labor patterns can vary from person to person, and could be slow to build in intensity. 

These contractions help the cervix to soften, thin out, and begin to dilate up to about 5-6cm. Early labor contractions usually last about 30-60 seconds, sometimes longer, and come anywhere from every 15-20 minutes to every 5-10 minutes, with the interval between contractions getting shorter over time.

As above, as long as you feel safe and don’t have any cause for concern - like bleeding, a fever, or intense pain -  the best thing to do is rest, eat, relax and surround yourself with supportive people. Taking care of your energy needs and tuning in to the final family moments before your baby’s arrival are a great way to connect, and stress or worry about the labor itself usually only serves to cause discomfort and slow things down.

Active Labor

Someone who has had their early labor contractions may feel like those were plenty “Active”, but the reason this stage of labor is referred to as such is because there is a lot more activity happening at this point in labor, both on the part of the laboring person and their baby.

In the U.S., most practitioners consider active labor to be when contractions are more consistent and the cervix has dilated to at least 6 centimeters. This is also when the baby starts to move and rotate through the pelvis at a faster rate, in most cases. During active labor, someone can expect their contractions to last about 45-90 seconds and come more closely together, about every 3-5 minutes.

With the increased frequency and duration of contractions, as well as the changes in pressure and sensation that may come with the baby's increased participation, many people feel the urge to be more active at this stage of their labor. And that’s great, because as described above, movement, rhythm, position changes, and touch can all help both parties to navigate the process. Staying hydrated is also incredibly important and, unless there is a true medical reason not to, eating and drinking at will are considered evidence-based ways to support labor progress.

Transition 

Technically a part of active labor, transition marks the process of final cervical dilation, from about 7-8cm to 10cm (equivalent to about 4 inches). This can be a very intense part of labor, because the internal opening of the cervix facilitates the baby’s continued descent through the bony pelvis and into the vagina, and many people experience a lot of pressure. 

Hormonal changes can also add to the intensity of transition by causing hot flashes, chills, shaking or heightened emotional sensitivity. Iit is a time when many people benefit from additional tender loving care, whether that means touch and encouragement, a good hug, or, depending on someone’s coping style and personality, some private alone time with trusted support nearby.

Thankfully, it is also usually the shortest part of labor, lasting just a few hours at most, and sometimes quite brief. In fact, it is often during transition that a laboring person will think they are at their mental or physical limit, only to find that their baby is born soon afterwards. During transition, contractions are usually longer, closer to 90 seconds each, and very close together, with sometimes only 30-60 seconds of recovery in between. Deep breaths, consistent hydration and the coping skills above can help someone move through this heightened labor contraction.

Pushing & Birth

Once a laboring person has reached full cervical dilation and is ready to start pushing, their uterus has been doing plenty of contracting and still takes care of most of the involuntary muscular action that goes into pushing. A person’s voluntary efforts may help the strength of these final contractions, and pushing usually takes some time to learn to do effectively if it is someone’s first time. 

Since a lot of effort is involved in the part of the laboring parent, and the baby is navigating a very constricted space in the pelvis during pushing, the body does some intelligent things to help both people succeed. One of those is that contractions may spread out to be further apart again - this gives the laboring person and their baby time to recover energy between pushes and oxygenate fully. Additionally, the contractions themselves may be a little longer or slower to build, or come in waves, to make the most of each pushing effort before another recovery pause.

There isn’t a hard rule for the contraction pattern at this time, but in addition to cervical dilation, another way to know a person is ready for pushing is if they feel an instinctual urge to bear down, similar to the pressure of an inevitable bowel movement. There may be some time that passes between transition and this point - sometimes contractions even stop all together so that the laboring person can rest for a bit - consider this the body’s way of taking a moment to recover before refocusing on the task at hand.

How to time a contraction

Since the frequency and duration of contractions is one indicator of labor progress, being able to assess your labor pattern at home can be very helpful in deciding what to do next and when to contact your provider or consider going to the location where you intend to have the majority of your labor and delivery your baby.

The image below is similar to the readout from an external monitor one might find in a hospital setting. These readouts aren’t always accurate, and so the laboring person - not the paper readout or computer screen - is the truest indicator of what is going on. Please note that the “mound” representing the peak intensity in this image is, in real life, 100% subjective - no one but a laboring person can feel or say how strong their contraction is, but the monitor readout will be used to give medical staff a general understanding of someone’s pattern. In this example, we are simply showing the representation of a contraction over time to illustrate how to measure it.

  1. At the start of a contraction, note the time or set a timer. The laboring person may feel a contraction coming and signal that verbally or through their posture, energy or breath. 
  2. When the contraction ends or fades, mark the time or stop the timer - this will tell you the duration of the contraction, or how long it lasted. In the image above, the first contraction lasted about 1 minute.
  3. At the start of the next contraction, note the time and/or restart the timer. You will be able to measure the duration of this contraction as you did with the last one. The time that passes between the end of one contraction and the beginning of another marks the frequency of contractions by measuring the interval in between. In the image above, 

Labor timing tips

  • Have a helper time them. While occasionally noting whether Braxton-Hicks or early labor contractions have changed dramatically is totally fine, and it makes sense someone might want to time their own contractions before involving anyone else, overall, focusing on the numbers and analytics is often counterproductive to labor progress. For one, it requires a lot of left-brain thinking and analysis of linear concepts, and labor is a very right-brained activity, so it can take someone “out of the zone” if they are very focused on the timeline. Secondly, if a labor’s rhythm is not yet established or the reality of someone’s labor pattern doesn’t meet their expectations, timing contractions may cause additional stress.
  • Don’t worry if you miss a few. Labor for a first time birthing person can last, on average, about 24 hours from those earliest contractions to delivery. Especially with all the eating, sleeping and downtime that ideally happens in that period, it’s okay not to track everything! Simply start timing them again next chance you get and make a note that you were distracted for the other ones. The measurements are not what determine the journey, just a helpful detail!
  • Change is good! And usually gradual. If the labor pattern does change, give it some time to see if it stays there, or changes again. The laboring person may also change the way they communicate the contractions, and that’s usually a sign of progress. If a person who was speaking up about each contraction has started to turn inwards, breathe deeply or walk around instead of saying something, that’s probably a sign they are getting in their zone and labor is progressing. 

The 5-1-1 Rule

We’ve covered the mechanics, sensations and patterns of labor contractions, as well as how to time them. So what’s this 5-1-1 rule you’ve heard about? Read on for this simple rule for assessing labor progress at home.

How to use it

When timing contractions at home, someone may want to assess their labor progress to decide when to contact their care provider or, if they are birthing at a clinical facility, when to move locations. One might want to avoid the possibility of going in too early, only to be sent home if contractions aren’t frequent enough or their cervix isn’t dilated. The 5-1-1 Rule - sometimes also modified to “4-1-1”,  is just one way to inform these decisions - it is a decent indicator of labor progress because it reflects a pattern typical at the end of early labor and the beginning of active labor.

  • Contractions are 4-5 minutes apart
  • Contractions last about 1 minute each
  • This pattern lasts for at least 1 hour

Note that the continuation of the pattern for at least an hour or so is important. Since labor isn’t linear, it can sometimes speed up and slow down, so give yourself some time to see if the 4-5 minute frequency of contractions sustains. Of course, rules like this are only tools, and not absolutes! If you feel like you want to stay home longer, or have a sense that you should go in sooner, do what you need to to feel safe, honor your instincts, and get more information as needed.

Other signs of labor progress

The contraction patterns we’ve covered are just one way to assess what is happening in someone’s labor. There are also other ways to assess labor progress, and because it is such a unique process that engages body, mind, psyche and spirit, some of these are not easily quantified on paper. Consider these other experiences as you or your loved one moves through labor, understanding that no one experience of labor is the same.

  • The waters breaking, featured so often in entertainment media, usually isn’t the first sign of labor. The amniotic sac usually ruptures at some point in active labor and may result in a trickle or gush of amniotic fluid - it’s only the first sign of labor in about 10% of pregnancies. 
  • Change in sounds coming from the laboring person. While early in labor, a person is more likely to be chatty and sociable, but as the hormones and exertion of labor progresses, they may become less talkative or use more moans, sighs and simple one-word responses than regular conversational styles. They may also make deep, guttural, grunty sounds as pushing approaches, or simply have no tolerance for other people’s jokes or chit-chat.
  • Change in movement - we’ve discussed how important changing positions is. The previously less active laboring person may feel an urge to get up, squat, walk around, jiggle, get on their hands and knees or sit on the toilet - these are all good signs that internal changes are happening!
  • Symptoms of hormonal shifts - we mentioned above some of the side effects of transition. Strangely enough, some of the less pleasant symptoms, including nausea, hot flashes, vomiting and shakiness, are all rather positive signs of progress in the context of labor.

When to call your medical provider

Hopefully the 4-1-1 or 5-1-1 Rule is helpful in your assessment of labor contractions at home. However, that isn’t the only time you might decide to call your medical provider, and it also isn’t required to go into the hospital just because you are having contractions regularly. Here are other reasons to call your prenatal health care provider in the context of labor starting.

Signs of labor progress

  • Your labor contraction pattern picks up quickly or exceeds the rule above, or you simply feel there has been a significant change and want to speak to your provider.
  • Your water breaks at home - you will want to note the Time; Amount (i.e. “a soaked pad”, “a foot-wide puddle on the floor”, “a trickle”, “a gush when I was peeing); Color and Odor. Amniotic fluid is usually clear or off-white with some mucus, pink tinge or yellow tinge, and may smell like a mix of saltwater, body odor and urine.
  • You start feeling like you have to poop even if you have already used the bathroom and/or are unable to pass a bowel movement despite the urge
  • You experience shaking, temperature shifts, or an intensity in labor that suggests you might be in transition

Signs to seek medical care for you or your baby’s safety

  • Your waters break and you notice a foul or fishy odor, or brown, black, green or bloody color. 
  • Any sign of infection, including fever, or foul-smelling or discolored vaginal discharge.
  • Any spotting or bleeding of fresh blood beyond a small streak or tinge.
  • Noticing a significant and unusual decrease in your baby’s movements, with or without contractions starting.
  • Any sudden swelling, particularly at the face and hands or if accompanied by changes in vision or headaches.
  • Any serious changes in vision, headaches, pain, balance or other signs that something is wrong. Trust your intuition!

If you are earlier than 37 weeks and you have any signs of labor beyond your typical Braxton-Hicks activity, you should call your provider. This could include:

  • Regular or frequent contractions
  • Increasing pelvic pressure or cramping that doesn’t go away with eating, drinking water, resting or movement
  • A constant low, dull backache beyond typical for you
  • Premature rupture of membranes, resulting in a gush or leak of amniotic fluid or particularly watery vaginal discharge 
  • Fresh bleeding or more than a slight tinge or small streak of blood in your discharge
  • Any of the other signs of labor or symptoms listed above

Jessalyn Ballerano
Certified Childbirth Educator & Doula
Jessalyn (she/her) is a Childbirth Educator and Doula serving families in the San Francisco Bay Area, nationwide, and in her new home of Eugene, Oregon. She started studying birth in 2010 as an anthropologist, and often brings a systemic approach to helping birthing people to understand their options, experiences and possibilities. She integrates evidence-based training and research with a holistic mindset and an activist’s passion for reproductive empowerment. Jessalyn serves on the board for the Oakland Better Birth Foundation, where birthworkers, birthing people, and care providers work together to end preventable maternal and infant mortality and address racial disparities in health care. Jessalyn is a CAPPA-Certified Childbirth Educator, SMC Full-Circle Doula.
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