While there are no statistics as to how often and how many women are sent home from the hospital in the early stages of labor, the issue appears to be front of mind for many. Numerous online message boards offer tips for women to avoid being sent home and online articles share advice for those who have been.
ABC News’ Chief Medical Correspondent, Dr. Jennifer Ashton, who has delivered more than 1,500 babies, said that “obstetric management of early labor and active labor is both a science as well as an art.”
Doctors consider numerous factors, including if it’s a woman’s first labor, if the pregnancy is high-risk and whether fetal heartbeat patterns are reassuring, as well as how far away the patient lives, according to Ashton.
“If you think of labor and delivery as an ICU for pregnant women with continuous monitoring and often 1-to-1 nursing, it’s easy to understand how sometimes there are not free beds to admit women who don’t yet meet the above criteria.” said Ashton.“To be clear, it’s never ideal to send a women home and have her deliver outside of the hospital.”
Some research also indicates that there are benefits to delaying admission to labor and delivery wards, including fewer medical interventions as well as better outcomes.
Women who spoke to ABC News regarding the difficulties in their labor experience said they understood the procedures in place when it comes to admitting pregnant women and each had known that not being admitted because of early labor was a possibility. However, they felt they weren’t being heard when it came to their own feelings.
“Sometimes it’s not about policy and procedures,” Harris said. “It’s about doing what’s right. Women know their bodies … Why are we being dismissed?”
‘See you next week’
Harris, 30, said she was sent home from a Dallas hospital after a doctor told her she was “rushing things” because she wasn’t 4 cm dilated, she told ABC News. She was 40 weeks along at the time.
A number of factors come into play as to whether a hospital admits a woman in labor, depending on risk and other parameters. Among them is whether the woman is in active labor, which is gauged by cervical dilation. Guidelines changed in 2014 from 4 cm to 6 cm dilation to help avoid unnecessary C-sections.
“He said it could be another week and we were just kind of looking confused. I’m like ‘OK. No, this is not another week,’” she said.
Her contractions were consistently 5 minutes apart, had reached a point of being unbearable, and the nurse said she her cervix was 95% effaced, according to Harris — all indicators of how far along labor is.
“I have two other children,” she remembered thinking that day, July 1, 2017. “I think I know when my body is ready.”
Even so, she still left the hospital — a decision she now regrets.
Harris said staff sent her off with drugs to relieve the pain and a nurse told her, “see you next week, probably.”
Less than two hours after leaving, they rushed back to the hospital, with Harris giving birth to a baby boy just as they pulled up. Harris’ son had the umbilical cord wrapped around his neck when he was delivered, she said. Nurses rushed out and managed to successfully unwrap the cord, but Harris remembers being terrified.
“I don’t remember hearing him fully cry until we got into the room in the hospital,” she said.
Her son’s birth time was listed as 11:45 a.m., but Harris thought it was closer to 11:35 a.m.
“They didn’t know what time to put because they weren’t there,” she said.
Active labor guidelines
The American College of Obstetricians and Gynecologists (ACOG) said active labor for most women does not occur until 5 to 6 cm dilation, according to the association’s guidelines.
ACOG said, per its guidelines, which are not mandatory, that if a woman is not admitted to a labor unit, “a process of shared decision making is recommended to create a plan for self-care activities and coping techniques.”
Dr. Wendy Wilcox, an OB-GYN in Brooklyn, said the process of admitting a woman in labor goes far beyond just one factor, such as their cervix dilation or contractions.
Doctors also check the mom’s vital signs, baby’s heartbeat, the patient’s medical and birthing history and if there is any vaginal bleeding, Wilcox told ABC News.
Dr. Rade Vukmir, an emergency medicine physician in Michigan, said about 30% to 50% of women in the obstetrics triage unit experience early labor, also known as the latent phase. Physicians are supposed to provide proper medical care to determine if a woman is actually near labor or in the latent phase. If it’s the latter, those women are then sent home, he said.
“Labor starts at this early, so-called latent phase … so we say, ‘OK, you’re in labor until we prove you’re not in labor.’ That’s where things get kind of complicated,” Vukmir told ABC News.
Studies concerning admitting women in early labor have produced different results, according to an ACOG committee opinion from February 2019. Some observational studies have found that doing so led to more medical interventions as well as C-sections, but the studies weren’t able to discern if that was attributable to longer exposure to the hospital environment or a “propensity for dysfunctional labor,” according to ACOG.
On the other hand, a 1998 randomized controlled trial cited by ACOG found that delayed admission produced better outcomes, including “lower epidural use and augmentation” as well as greater satisfaction in the experience.
And a 2015 study found that, in addition to potentially saving $694 million, delayed admission to labor wards would result in 672,000 fewer epidurals as well as 67,000 fewer C-sections in a theoretical cohort of 3.2 million low-risk women.
“Admission to labor and delivery may be delayed for women in the latent phase of labor when their status and their fetuses’ status are reassuring,” ACOG said in its 2019 opinion. “The women can be offered frequent contact and support, as well as nonpharmacologic pain management measures.”
Some instances of not providing appropriate care for women in labor have resulted in fines and violations of law. Over the years, hospitals that participate in Medicare have been fined under the 1986 Emergency Medical Treatment and Labor Act (EMTALA), which regulates medical screening and patient transfer in emergency situations.
About 6% to 8.5% of the more than 2,800 EMTALA complaints from 2014 to 2018 were related to labor in hospitals, according to data from the Centers for Medicare & Medicaid Services. Of those complaints, the majority (53% to 82%) were determined to be EMTALA violations, the data showed.
It was not clear how many of those cases were for women being turned away in labor, and the cases represent just a fraction of the total number of live births in the country each year. Officials did not provide the details of the cases and ABC News has not reviewed them.
But some of the most egregious EMTALA violations are listed on the Department of Health and Human Services Inspector General’s website.
In a 2015 case, for instance, a Kansas hospital “did not record the patient’s medical history, take any vitals, conduct fetal monitoring, test for fetal movement, or perform any exam on the patient,” who was 38 weeks pregnant and complaining of abdominal and lower back pain. She delivered a stillborn baby at another hospital, according to a report from the HHS OIG.
The hospital in the Virginia case where the mother gave birth in a bathtub is not required to comply with EMTALA as it is a military facility, a Health and Human Services official said.
‘I think I know’
Two other women spoke to ABC News about being sent home from the hospital after reading about the Virginia couple’s story.
Lesli Newton, a 39-year-old Cincinnati resident, said she was 37 weeks pregnant when she began experiencing contractions on the night of Feb. 7, 2015. She had two other children at the time, two girls with her third on the way, and knew what labor felt like.
She and her husband went to a local hospital around 10 p.m. where the nurses performed a cervical check (she was 4 cm) and put a fetal monitor on her stomach. Ultimately, Newton said, they told her she wasn’t in labor.
Newton asked the nurses to call the OB-GYN, but she said she was told he was on a golf retreat. When they did phone him, according to Newton, the nurses said the doctor maintained what they had said: She wasn’t ready.
“This is baby number three, I think I know … but I was still going to take their word because they’re the nurses and he’s the doctor,” she said.
By the time she got home, the contractions became “really heavy and really painful.” Just minutes after they walked in the door and Newton managed to make it upstairs, she began to feel a sensation of needing to push.
Her husband called for an ambulance and Newton began pushing. By the time EMTs arrived, her daughter was crowning.
She managed to safely give birth to a baby girl in her room upstairs.
Liz Kimller, 33, of Orlando, said she remembers her contractions felt like a “9 out of 10” in terms of pain by the time she arrived at the hospital in February of this year.
The nurses, she said, wouldn’t admit her because she was only 2 cm dilated but they checked on her periodically in the triage at a local hospital.
At one point, Kimller said a nurse told her if she were in true labor, she wouldn’t be able to talk through the contractions.
“I felt like I couldn’t talk because when she was asking me questions, I had to put my hand up as if to say ‘Hold on a minute,’ and I was, like, screaming in pain,” Kimller said.
After being in the hospital for about two hours, she and her fiance were sent home. Kimller’s water broke about an hour after that.
Her pain, she said, had increased to beyond a 10 at that point.
“I felt like they should have known that if I’m in too much pain then that means something. That means I’m very close,” she said. “Which I was.”
Kimller and her fiance chose to drive to a different hospital, where she delivered a healthy baby girl.
But the experience still weighs on her.
“For me, this is my first time and I honestly felt as if I was dying and they don’t believe me,” Kimller said.
ACOG did not comment on specific cases. While the association’s guidelines recommend doctors and patients engage in shared decision making, those guidelines are not mandated and are followed at the discretion of the hospital and provider.
‘I’ve had patients push back’
Dr. Elizabeth Langen, an obstetrician at University of Michigan’s Von Voigtlander Women’s Hospital, told ABC News that she got into the profession because she thinks “birth is a beautiful process.”
“I want to help women and babies come through birth physically and emotionally healthy,” said Langen, who is also a member of the Michigan Obstetrics Initiative, a data driven quality-improvement project that includes 73 maternity hospitals throughout the state trying to increase the safety of childbirth.
She cited studies that suggest admitting women in early stages of labor are associated with higher risk of C-section. Langen also said that delayed admission led to higher patient satisfaction and a lower rate of other medical intervention.
“Our goal for delayed admission is to optimize women’s outcomes,” she said.
Langen suggests working on a birth partnership document with their doctor or midwife prior to labor and if she finds herself wanting admission when it’s not recommended, she says “express her needs to the team.”
“The team may not understand the concerns she has about discharge and she may not fully understand the reasons the team is recommending that she not be admitted,” Langen added. “Coming to a shared understanding of her goals for her birth is essential.”
Wilcox similarly said that “no one comes to work wanting to do a bad job.”
But she offered advice to any woman who feels as though they aren’t being heard by their doctors: Advocate for yourself.
“I’ve had patients push back,” she said. “I’ve said, ‘I don’t think you’re ready yet,’ and a patient said, ‘I’m not going home.'”