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How to know when Vaginal Exams in Pregnancy and Labour are useful and when they are harmful?

Vaginal Exams  are commonly done in labour by nurses, doctors and midwives to find out how dilated the labouring mom’s cervix is. Other terms that refer to the same procedure are VE’s, Internal Exams or Pelvic Exams. It is basically putting two fingers in the vagina all the way up to the cervix to feel :

1. How DILATED (open) the cervix is

2. How soft and short the cervix is (EFFACED)

3. Which direction the cervix is facing – POSTERIOR (to the back) or ANTERIOR (to the front, when labour progresses)

4. Where the baby’s head is in relation tot he pelvic bones (STATION)

5. And what position the baby’s head is facing.

While this can be a very useful procedure to find out very useful information, women also need to understand the full picture.

First of all, the damn thing hurts. It ranges from slightly uncomfortable to downright excruciating. Now remember, in nature female animals and humans don’t regularly go around sticking things up their cervix to cause even more pain and irritation when doing one of the most difficult and intense jobs in their lives – giving birth.

Secondly, it is not an exact science. It is not as if they are putting a ruler in down there. They’re just feeling around and making an estimate with their fingers and their experience.

Thirdly, having too many done can introduce germs and cause an infection, especially if several are done after the water has broken. In general, VE’s should be kept to a minimum and used wisely, but after the water has broken, this guideline should be followed even more strictly. I have seen some births where The rupture of membranes happened days before birth (called premature rupture of membranes), but there was no infection because they were extremely careful to avoid internal exams and instead assess progress by external signs. And I have seen births where the rupture of membranes happened normally at the start of labour * but an unnecessary number of pelvic exams were done, only to cause infections in the mom so that they had to have cesareans.

* Note : Most labours start with contractions and the water breaks towards the end of labour (around transition which is between 8 – 10cm dilation). Only 20% of labour start with the water breaking and then contractions follow soon after. If contractions don’t start within 12 hours of the water breaking, it is called Premature Rupture of Membranes (PROM). 

Be wary of having students nurses, doctors or midwives at your labour. They need to learn how to do VE’s effectively, so they do one, then the mentor does one to make sure they’re estimate is right. Then when there is a shift change, the new person might want to do another one. All of this is unnecessary and simply risky once the water has broken.

Some caregivers do internal exams towards the end of pregnancy because they want to guestimate how soon you’re labour will start. Some caregivers don’t do any internals before labour because they don’t see any point in it. They figure labour will start when it starts. There are some changes that take place before labour. The thing is, there is no way of knowing when labour will start because the changes can take place, but then no action may happen for weeks, or no changes may happen and then in a very short time, everything can happen and labour can be quick.

About.com provides a brilliant article in their Pregnancy and Childbirth called The Myth of Vaginal Exams

Labor is not simply about a cervix that has dilated, softened or anything else. A woman can be very dilated and not have her baby before herdue date or even near her due date. I’ve personally had women who were 6 centimeters dilated for weeks. Then there is the sad woman who calls me to say that her cervix is high and tight, she’s been told that this baby isn’t coming for awhile, only to be at her side as she gives birth within 24 hours. Vaginal exams are just not good predictors of when labor will start.

Some practitioners routinely do what is called stripping the membranes, which simply separates the bag of waters from the cervix. The thought behind this is that it will stimulate the production of prostaglandins to help labor begin and irritate the cervix causing it to contract. This has not been shown to be effective for everyone and does have the aforementioned risks.

So another reason some caregivers do weekly pelvic exams from about 37 weeks onwards is, if the cervix is slightly dilated enough to fit a finger in, they might try separating the amniotic sac from the uterus to try to hasten the start of labour. Some caregivers ask for permission before doing this, but some don’t even inform the women about what they are doing. So if you do not want his done, make sure you discuss it before allowing a pelvic exam in pregnancy. A lot of women get fed up with being pregnant and want this procedure done in hopes of speeding up the start of labour. But not all women want to do that. Know what you want and let your caregiver know what you want.

Fourthly, the results of a VE can be very discouraging if they aren’t what you expect. A woman who is in intense labour with contractions coming one on top of the other may be feeling that she’s in transition, yet have a VE say she’s only 6cm. This can be discouraging. The thing is, she may actually progress very quickly to 10. Where you are now has no relationship whatsoever with how fast you are going.

The fifth thing to consider will help you determine when a pelvic exam might be useful and when it might be useless or harmful – Will the information from the exam help us make a decision about the course of action ?

A lot of vaginal exams are done just for the heck of it to “assess progress”. Most of the time this is unnecessary and leads to unnecessary cesareans. Sometimes there may be no dilation for hours. There can be several reasons for this :

  • The baby might be rotating into a better position to fit through the pelvis. To understand how the baby’s rotation can help it fit, watch my video at Understanding Optimal Fetal Positioning.
  • The mom might be feeling anxious or stressed, which can inhibit labour from progressing. To understand how emotions can effect labour, Read my article.
  • Or there may be a genuine problem that cannot be solved except with medical intervention.
So the question to ask your caregiver if they are suggesting an exam that you are unsure about is, “What will you find out from the exam and what might you do based on what you find out?”

Usually two basic VE’s are done in labour, although sometimes even these are not necessary. One is when you get to the hospital, or if you are having a homebirth, when the midwife gets to your house. They usually do a VE to check if you are in active labour (4cm or more). Before active labour, the hospital will send you home, and the midwife will go home. Early labour can take hours and there is no point of being in the hospital before then unless there is some medical problem. If you are past 4cm, they will get you a room in the hospital, or the homebirth midwife might call the second midwife to get ready to come.

The second VE may be done when you feel an overwhelming urge to push. They may want to make sure there is no cervical lip left before you start pushing. In both these cases, action will be taken based on the results of the VE.

Other times that a VE may be useful are when a mom is really asking for medical pain relief. The amount of dilation will determine what kind of pain relief (epidural or morphine) may be appropriate or whether labour is close to the end and maybe no pain relief is necessary.

The thing is, some VE’s are done just for the sake of charting purposes. There is a ridiculous theory that dilation ought to be at least one cm every 2 hours. It doesn’t take a rocket scientist to figure out that different people do things at different rates and that’s ok. It doesn’t mean anything is wrong.

The important thing is to limit the number of VE’s done by figuring out if the information they provide will help you and your caregiver make decisions about what to do next. Don’t take the results of VE’s to seriously. Don’t get discouraged if it’s not what you expect. (I know that’s easier said than done.) And try to have only one person do the VE’s in labour instead of different people and different opinions.

 

To find out more about prenatal education, natural birth information or doula support in labour in Surrey or Langley BC email kaurina @ prenataljourney.ca or call 604 809 3288.

 

Great article called “What is the evidence for doulas?”

Ok, this is probably the most comprehensive explanation of why someone might want to hire a doula I have ever read, and it comes complete with a concept diagram of the whole thing!

Rebecca Dekker starts out by saying,

When I was pregnant with my first child, I briefly considered hiring a doula. I saw the doula flyers at Baby Moon, where I did prenatal yoga, and I thought it sounded kind of cool. But when I talked to my husband about it, he felt a little squeamish about the idea. We are both pretty private people (although you wouldn’t think it now that I blog about birth), and he didn’t want anybody else there. He just wanted it to be him and me. And he felt like he would do a good job of supporting me. At the time, it made sense. But hindsight, as they say, is 20-20.

Now all I can say is what were we thinking? How could it possibly be just him and me at the birth, anyways? We were planning to birth in a hospital! A teaching hospital, no less! Where there would be strange residents and students coming and going, and where we had no control over who we got as a labor and delivery nurse. And this was my first birth! It is so important to avoid a C-section in your first birth, because that sets the tone and risk level for all of the rest of your births (and we wanted to have at least 4 children, too). I knew on some mental level that doulas lower the risk of C-section, but I guess I just didn’t realize how important doulas are. Well, I do now. So today, I am going to talk to you about the evidence for having a doula present at your birth.

So true! I can relate because during my first pregnancy, I couldn’t imagine what I would need a doula for too. All that changed once I was in labour. To read my story you can go to Birth Stories.

Rebecca goes on to explain the randomized controlled trials that prove how effective doulas can be for improving labour and baby outcomes. To read the rest of the article, click read the article here.

The absolute craziest thing is how after so much research, the medical profession isn’t like totally promoting doulas to every pregnant woman. The fact is, if doulas were a drug, it would be unethical not to recommend them. But they’re not a drug. They’re people. And so, right now, only the people who already get it, are choosing to have a doula. I hope by the time my daughter is having kids, every pregnant woman is informed about doulas and exactly how they can help, so she can make an informed choice, instead of of what I usually hear, which is, “I wish I had known about doulas BEFORE I gave birth!”

Respecting the Mother’s Preferences for Birth

Yesterday I did a quick review of the new internet channel about birth – http://www.oneworldbirth.net/ . After giving it more thought, I decided to add a point that I think is critically important in the debate, yet is often completely ignored. That is, what does the mom prefer for her own birth?

What does the mom prefer?! How does that matter?! Isn`t it just a question of safety and risk? Life or death?

Well, remember, in my review post I talked about most decisions in childbirth being in the grey area. What that means is there may be some risks to not using medical intervention, and some risks to using medical intervention. So caregivers and parents have to make a decision based on balancing the risks.

Because we are talking about those grey area situations right now, and not the out and out real and immediate emergencies, I would like to suggest that one critically important factor in deciding the course of action, besides weighing the risks, is knowing what the moms preferences are for her birth.

Seems simple really, but it is quite profound and has long lasting effects. Here`s why –

There are roughly 3 groups of women – Women who really don`t like medical interventions, women who do want medical interventions, and women who don`t care either way.  You may argue about which group is more common, or why they feel the way they do, but no one can deny that there are these three groups.

It`s funny because the women who really prefer natural birth simply can`t understand why some women don`t, and the women who really want a medical birth cannot fathom why anyone would want a natural birth. The point is not which is a better way. There is no such thing. The point is that different women prefer different experiences. The childbirth “Experts“ can debate all they want, but what do they women actually doing the birthing think?

Why this is so important is this : Say a woman who really wants a normal birth, goes to the hospital and has a long labor. The doctor comes in at some point and says, “Well, this has gone on for too long. I think we may as well do a cesarean.“The well-intentioned doctor may well be thinking, “No sense in letting her suffer. I`ll help her out by getting the baby out now and putting an end to her pain.“ This is an example of a grey area situation where there is no signs of distress in mother or baby. (i`m not talking about situations where there is a clear problem and a cesarean is clearly the best option.)

If the mom doesn`t have a discussion with the doctor about risks, benefits and her preferences, she may go on to have the cesarean then end up wondering for the rest of her life if it was really necessary. Besides physical effects, there can be emotional effects which can affect her self-confidence as a woman and as a mother.

If however, the woman doesn`t care either way, normal birth or cesarean, then she may be totally happy with her experience and won`t feel the same emotions as the woman who actually wanted the vaginal birth.

If the woman actually wanted a cesarean to start with, she would be so relieved and totally happy with her experience.

The thing is the doctor does not know which of these three categories of women his client is in. The doctor may not even know there are three categories. If you have a preference, it is your job to figure out what it is, and to communicate it with your doctor. It is easier to have these discussions during your prenatal visits rather than in thee middle of labor, although you can still discuss things as they arise.

That woman in the first example may still choose to go ahead with the cesarean, or she may not. But if she has a discussion with her doctor or midwife and takes into account her preference, she will feel much better about her experience, and feel more confident about herself and be more relaxed as a mom.

I hope you found this article helpful. Please leave your thoughts in the comment box. If you would like to schedule a birth consultation to clarify your preferences for birth (otherwise known as a Birth Plan) and write a list of important questions to discuss with your caregiver in prenatal visits, call 604 809 3288 or email kaurina @ prenatal journey . ca

 

© copyright 2011 Kaurina Danu The Prenatal Journey