Monday, February 1, 2010

Forgoing vaginal examinations during labor

This post is for Science & Sensibility's "Healthy Birth Blog Carnival #4: Avoid interventions that are not medically necessary." Check back at Science & Sensibility for other entries when the carnival goes live! [ETA updated link]

As birth has become medicalized, routine interventions in labor have become more and more common. This Lamaze Healthy Birth Practice Paper identifies some of these: intravenous fluids, restrictions on eating and drinking, continuous electronic fetal monitoring, artificial rupturing of the membranes (breaking the waters), augmentation of labor (such as with Pitocin), epidural analgesia, and episiotomies.

When I was pregnant, I read about all these interventions in books like Henci Goer's The Thinking Woman's Guide to a Better Birth and decided, based on the evidence showing that fewer interventions lead to better outcomes for mother and baby, to avoid any interventions I reasonably could.

One intervention I didn't avoid during childbirth that I'd like to be more assertive about next time? Vaginal exams.

Care providers use vaginal examinations during (or preceding) labor to check the dilation and effacement of the cervix. There's an expectation within the medical community that such measurements give meaningful data, from which predictions can be formed. Many birthing professionals still subscribe to outdated notions that birthing women's dilations proceed at a fixed rate along a set curve, when actually very few women fit the "average" mold (this is a universal truth that is universally ignored!) and due to the elastic nature of the cervix itself, many birthing women's (healthy, normal) progression is actually much more variable than a straight line. Women can be seemingly "stuck" at a certain dilation, but that doesn't mean that something is wrong or that the body isn't still preparing for the impending birth. In addition, measurements of dilation and effacement are somewhat subjective, since they're done, blind, with fingers and involve approximations of width to get an idea of the centimeters; therefore, this also presumes that every woman progresses to exactly the same width and that every care provider measures the progression in the same way.

Here's my own experience with vaginal exams during labor, and why next time I would like to avoid them. I went into labor in the late morning of Day 1. (Yes, I need to differentiate the time passed by days!) I spent until the evening trying to distract myself from the labor waves, but by evening I ended up in the birthing pool with Sam. All of the pressure was going toward my back, so he applied some magical counterpressure to every contraction.

By early morning on Day 2, we decided, based on the timing between and during contractions, to call in the midwives. They arrived late in the morning of Day 2, and the first thing they wanted to do was a vaginal exam.

I was wary, because I had thought I would refuse. I knew the evidence that vaginal exams are not all that when determining progression. I knew of the strong probability that an exam would only depress me rather than encourage me. But there were two factors weighing against my good intentions: One is that the midwives wanted to do an exam, and I felt churlish refusing. Two is that I was hoping for really good news, dreaming I was at 8 centimeters and would be giving birth within a very short time. So I consented.

I was at 4-5 centimeters dilated, out of 10. This was not the news I'd wanted to hear. I'd been in labor now for 24 hours and had hoped to have more objective evidence of "progress." Clearly, all of the labor waves going through me were shouting out to me: "This is progress! A baby's coming!" But the medical mindset of centimeters and comparing to averages is strong, even in a person attended by midwives and trying for a home birth and educated about the fallacies concerning the common interventions.

But we kept on keeping on, because what else can a woman in labor do? I labored. I labored all day long.

The main midwife checked me at least one more time during the day, and had a student midwife do so as well, for practice and comparison. I hoped maybe she would get a different reading, based on differences in finger size or optimism. But, no, still around a 5.

I tried not to be discouraged. The pressure in my back was intense. Sam continued to help me with counterpressure on my back, we went on several slow walks along the beach, and I spent a lot of time in the shower, doing lunges, and bouncing on the birth ball.

With all this work I was doing, surely I was now at an 8 or so?

Another check. Another 5.

It was late at night on Day 2 now. The midwives were concerned about my dehydration and consequent fever, since my body was working so hard it couldn't keep anything down (another sign that dilation isn't the only measure of labor!). I was doing well; the baby's heartbeat was strong. But the midwives worried that, if I'd been at 5 cm all this time — well, what if I just stayed and stayed at 5 for who knows how long? The working theory was that the baby was turned the wrong way and not putting even pressure on the cervix, which is why it wasn't dilating as expected.

It was decided that we would transfer to the hospital. I could have some more of those interventions I'd been trying to avoid, and we'd see what happened from there. It was now the early hours of Day 3.

While getting ready for the hospital, the contractions grew ever more intense. I felt like I could feel the baby spinning. I thought maybe it was in my head — that it was my emotions acting up, my resistance to transferring to the hospital. The midwives agreed that my actions and concentration seemed more intense than before and suggested ... another vaginal exam!

I crossed my fingers. I was at 5 cm.

We got in the car.

It was while we were driving to the hospital that I started bucking bodily off the seat. Something was happening inside me, something over which I had no control.

We got to the hospital, and there was the usual rigmarole of checking in and monitoring, somewhat truncated by the advanced stage of my labor (but not enough for my taste!). I was getting frantic by this point, telling anyone who would listen (and few would) that I felt like I needed to push. The nurses all told me to simmer down and hold on and not push.

Alerted finally by my insistence, the nurse-midwife in charge agreed to give me ... a vaginal exam! It was my lucky day.

What did she discover? That I was at 5 cm!

No, I'm not even joking. My cervix was determined not to budge.

But ... the nurse-midwife noticed something. She discovered that really just one small band of ultra-tough tissue was keeping my cervix from dilating further. She asked if I wanted her to try to move that tissue aside with the next contraction.

One on hand, I'd been trying to avoid interventions such as that. On the other hand ... heck, yeah! Anything to get this baby out at this point.

She pushed at the recalcitrant skin. Shazam! I went from a 5 to a 10, just like that. I was complete. This baby was on his way!

After a very short rest, I started feeling a true urge to push, and was given the green light to do so. After an hour and a half of pushing — and 42 hours of labor all told — my 11 pound, 13 ounce, little guy came on out.

He had been tilted a little funny, since he had one hand up near his head. I had been scared of the idea of a nuchal arm, just a particular little phobia of mine, and I got it — but it didn't cause any problems on exit.

As for my supposedly "stuck" dilation that all those vaginal exams exposed? Maybe the nuchal arm and tilted head had contributed to the slow dilation of my cervix because of a lack of consistent pressure. Maybe he had been posterior, which would explain the back labor as well as the slower progress. Maybe it was the stubbornly tough tissue. Maybe it was his tremendous size that simply demanded more time to stretch the canal and get things ready.

In the end, it doesn't really matter. What I do know, in hindsight, was that being told multiple times that I was still at 5 centimeters — that there had been no discernible progress despite all the apparent activity taking place within me — was an unnecessary discouragement. It didn't change the course of the labor, except by influencing decisions to perform more interventions: breaking my waters and transferring to the hospital among them.

I honestly don't know if I can be strong during my next birth (if I have one) and refuse vaginal examinations the whole time. The temptation to conform and have some extra pieces of data might be too great. But I hope I learned my lesson, and can live without the objective knowledge of measurements and just trust my body to tell me where I am along the labor curve. After all, babies don't have any idea how many centimeters the cervix has dilated, and they still mostly manage to come out at the right time!

What about you? How did vaginal exams help or hurt you during labor? Did you refuse, or did you want to, or did you desire the reassurance of facts?


Anonymous said...

I didn't really consider them an option during labor. I mostly avoided them during pregnancy, but then the last couple of visits the doctor did strip my membranes - talk about invasive!

At the time, I felt it was the right course of action. I was terrified that we would birth while our doctor was out of town at one or another convention. Meanwhile, he wanted our baby to come early because I had a history of large babies (8/10 and 8/9) and this time added Gestational Diabetes.

Sasha was born about a week early (I can not, for the life of me, remember her due date!) and weighed a healthy 7/8. Oh, and they did break my water. I was ready to encourage labor by then.

It is late & I can't remember what my point was or if I made it. Sorry.

Dr Sarah said...

My labours both went so fast that I hardly had time for any vaginal examinations. The first time, I got to the birthing centre, was examined, found to be fully dilated, and my son was born half an hour later. The second time, I got to the birthing centre, was examined, found to be about 3 - 4 cm with a cervix 1 cm thick, and my daughter was born half an hour later. So, no stories of unwanted vaginal examinations here, but a good example of how little those numbers mean in practice!

Geeks in Rome said...

My midwife's philosophy was do a vag. exam very rarely and then don't announce what the dialation is.

Unfortunately I had a different midwife with my first and she gave me a total of 3 exams during labor and told me the dialations each time. It was enormously painful (to lie on my back) but she was quick. She told me at my second check that I had only progressed 1 cm in 12 hours. That was real downer. It helped that she left to take her kids to school and the freedom of not having comeone evaluating me meant I dialated 6cms in 6 hours. She thought the baby would come at 8pm and I shot it out of there at 3pm because I was not going to be told I was making slow or no progress!

With number two I had my real midwife at the birth and she only checked me once or twice and I never noticed. She never said a word except "Don't push yet" when I wanted to push really badly. I must not have been fully dialated.

I think it serves more for the midwife to schedule when they have to get their birthing stuff together than for us.

Lauren Wayne said...

I totally forgot to mention how painful they were! You're right, Eurydice. My regular midwife's exams hurt much more than the student midwife's. At the time I wondered if the student was being more tentative and therefore gentler. I usually don't have a problem with pelvic exams, so I suppose it has something to do with the tenderness of the cervix, etc., during all that stretching.

Thanks for sharing your experiences, all of you! Jorje, I love that you're too tired to remember if you made your point. :) It was good to hear your story, and I got it. I felt the same way about having my waters broken — I was going to oppose it, but it was a last ditch effort to keep me home from the hospital.

Dionna @ Code Name: Mama said...

Not to mention they increase the risk of infection!
Very painful, so glad my midwife never tried to check me until I was in active labor (and even then I wish she hadn't - OUCH).

~Dionna @ Code Name: Mama

Olivia said...

My midwife didn't do any exams until the day after my due date. The next day labor started early morning, she came about 10 hrs later and waited another 2-4 hrs (time got fuzzy) before doing the first exam. I think I was 4 cm at that time.

She checked again about 4 hrs later because she thought my verbal and visual cues looked as if I was getting close to transition. I was 6 cm at that time. Throughout out the course of the night she check 2 more times, and each time I was 6 cm. Absolutely soul crushing given all the back labor I was experiencing.

About 24 hrs after labor started, she said the same thing your midwife did about the baby not being centered on the cervix and she was worried about dehydration and exhaustion. So, she suggested transferring and I agreed almost right away because I couldn't take any more back labor.

So, 4 exams at home with my midwife. Not too bad. Now the hospital is another story. I was checked when I got there. I was checked after I got settled in a room, and was checked I don't know how many times over the next 12 hrs. Nurse, doctor, intern, midwife...I refused the first several suggestions for a c-section, but consented to having my water broken because I felt it was a last ditch effort to get a vaginal birth.

I did get to 10 cm and pushed for 3 hrs, but she was just not coming down the birth canal and I had reached my breaking point. The c-section revealed her foot was by her head (a nuchal leg?). Hence, the back labor and her being too tilted to come down the birth canal.

So, I don't know what will happen next time. I do think my midwife's examinations did give valuable information even though they were discouraging for me.

I certainly could have done with fewer at the hospital, but they did have the value of relating progress to the docs which meant I could refuse the c-section (at the time this made sense).

Jenny said...

I labored long and hard (not as long as you though!) with my first in the hospital, and was checked a few times. The worst was when I was in horrible pain because my water had been broken artificially and I was lying in bed hooked up to the monitor. The nurse checked and I was expecting a 9, but I was just a 7 and she told me it could be several more hours. I was crushed and started crying. It was sort of ridiculous for her to predict that, because who knows how fast a woman will go? I finally had the baby vaginally, but hours after I got an epidural, which I did not want.

Second time around, I read about Sphincter Law. I definitely believe that a cervix can un-dilate, and I think it may have happened to me in the hospital. My awesome, amazing midwife doesn't even like to check for dilation, and she told me she'd find out all she needed to know just by watching how I was feeling and acting. She was right. My body started pushing on its own, and by the time I was actively trying to push, dilation was a moot point because we could see my membranes bulging out. Obviously, my cervix was out of the way. That labor went SO much better. I was never in what I'd call PAIN, it was just very intense. It only took about 8 hours total, counting from when I first knew for sure that I was in labor. I now have a deeper respect for the power of the mind and positive thinking during a birth. And I'd definitely recommend forgoing those vaginal exams.

Sybil Runs Things said...

I asked for them, both times. Each labor/delivery was very different, though.

The first time was extremely tough for me. At one point I was dilated to "almost" 10 and actually went back DOWN to like a 7 or something. Of course, that was completely defeating and then, after being in labor and not sleeping for two nights and my cervix contracting back shut, I asked to go to the hospital.

The second time I asked to be checked and got great news. It helped me power through and my baby was born at home.

Anonymous said...

During both of my labours I had 2 vaginal checks - one by my midwives at the beginning, and one when I was starting to push. With my first labour my water broke, and they consciously minimized the checks. With my 2nd the midwife came to my house to check me before I went to the hospital and she asked me if I really wanted to be checked. I did, because I was in major denial about being in labour. I was 3 cm, and didn't really take it as good or bad. For me, the checks weren't negative, but then I had very fast labours. For example, my 2nd son was born less than 2 hours after I was 3cm dilated.

Here's the thing I really wanted to say, that I have learned from both of my labours. I don't dilate steadily. I hang out at 3 cm dilated for the whole labour, and my cervix thins and thins. And then in a few swift contractions it dilates and the baby is born. I am basing this on the fact that in both of my labours at different stages of progress I was at 3cm, with a very consistent contraction pattern. And then there was some major intensity and things changed suddenly.

Had I had multiple checks, especially in my first labour, and learned that 5 hours after the first check I was 'still only' 3 cm it would have discouraged me. If I were to have a 3rd baby, though, if I'm 3 cm and having regular contractions I know that it's go time and I'd better get where I need to be unless I want to deliver in the car.

Anonymous said...

My midwife doesn't like to do vaginal exams routinely, however she did about 3 during my labor. The reason was that there was a chance I would have had some issues with dilation due to a procedure I'd had a few years prior. If I should be so lucky as to have a second child I believe I will forego the exams unless it's truly necessary.

Arwyn said...

I am trying to remember the last time a medical professional's fingers were in my vagina. It was my last pap smear, so... maybe ten years ago? (Yeah yeah, time for another, even if I have no risk factors.)

Point is, I didn't have any vaginal exams at any time during pregnancy or labor. They simply aren't necessary in most births, and shouldn't be performed unless specifically indicated or requested. My midwife (well, the apprentice) arrived right around when my body started bearing down (about two hours before birth). What information would a vaginal exam have brought us? I wasn't about to try to stop my body from doing what it was doing (for it was entirely involuntary) -- even if I thought I could have been successful, which I doubt! --, and it would have introduced pain and anxiety and the risk of infection.

The only time my midwives even saw my vagina was when they checked me for tears, at my request. That involved fingers on and very slightly in my vagina, but nothing near the invasiveness of a cervical check.

I absolutely own that I am lucky, that I had a straightforward pregnancy and birth, and some women need cervical checks, for one reason or another, and I am no "better" than they are, I don't get (nor want) any medals for having avoided that intervention, and I certainly hope this doesn't come across as bragging.

I just want to share the story, too infrequently told, of an uncomplicated birth, and how I simply didn't need internal exams. Mine wasn't a special birth, just a normal one: so why am I one of the few who didn't have fingers shoved inside her? (Those of you who know me know who, or rather what, I blame!)

Olivia said...

Arwyn, what your experience tells me is that cervical exams shouldn't be routine. They should only be done in accordance the the woman's request/consent and for true medical necessity (though I don't know exactly what that would be).

A friend just went thru a long hospital induction (37 wks pre-e). She said after a full day in the hospital she had to put her foot and and request that only her OB perform exams because every time a medical professional came into her room he/she was checking her cervix. Several were young interns and it made her uncomfortable.

Given the fact she was being induced, had a contraction monitor on and she wasn't feeling strong contractions, there was no medical reason to keep checking her.

Kate Wicker said...

I avoid vaginal exams at all cost. I'm usually checked at admission; yes, I do the natural birth thing in a hospital. The nurses are always shocked b/c I'm usually around 7 cm. Then my awesome midwife visits me periodically. I get serious, and I know it's time to push. Then I push my babies out in warp speed. (Not even one minute of pushing for my last baby.)

So I'm lucky, very lucky, but I also remember with my first them wanting to check me (I had a different midwife than I do now). I let them check once and I was more discouraged than anything. So when they returned to check my progress, I said, "No thanks."

When they came back the next time, I said, "It's time!" And it was.

Still, I recall having so many doubts, wondering if what they were all saying: That I was having dysfunctional labor (whatever that means), that I'd have to get on Pitocin (because my water broke early), that I wasn't in real labor even though it felt like real labor to me. Then it turned out that my body was right all along. It knew what it had to do. I just had to trust it.

I think that is at the crux of "natural" birth. Many women aren't as fortunate as me to have speedy labors that do not stall; however, we all have instincts telling us if something is right or something is wrong. But what modern medicine has done is tell us that pain is wrong, but normal pain isn't a sign that anything is wrong. I believe women need to feel the pain to know what to do. Some of us may have to have some medical interventions that are necessary, and our bodies will probably tell us that we might need help. Yet, most of our bodies will tell us that labor is going just fine and the way it should even if it hurts. We need to trust our bodies. We don't need vaginal exams or exact measurements to tell us labor is progressing or it isn't. We will know. And we're also stronger than we think.

Of course, I write this now, but even with my third child, I had some doubts right before I was holding her in my arms. This is so normal and a sign that you're sure to be holding your baby soon. If we can forge through these doubts, embrace the pain, and remember the outcome of this thing we call labor - a beautiful miracle of a child - then we're likely to have a more natural and fulfilling experience.

Please note, however, that I'm not trying to make any mom feel guilty who was unable to have the birth she desired. So much is out of our control. Labor and motherhood has taught me more than anything else that sometimes I have to step aside and let others or God take the steering wheel.

Great post! Sorry for the tome!

Anonymous said...

I had tons of checks, unfortunately! I started having contractions on a Saturday night and had them regularly until my son was born on Sunday...8 days later. They checked me several times Monday when I went in with contractions 3-5 minutes apart, only to discover I was dilated to 0. They sent me home & told me not to come back unless my water broke or I hurt a whole lot more. Then they checked me at the Ob-Gyn appt. Thurs when I was finally dilated to 1. Saturday my water broke & I went in to the hospital around midnight. They checked me every couple of hours. A nurse "stretched things out a little" and got me to 7 by 3 am, but I never got beyond that and they eventually did a c-section. It hurt like heck everytime and was depressing to know I wasn't making any progress. I wish I would've been more assertive requesting fewer or no exams, as studies have shown infection is caused by the checks, not just because your water is broken.

Anonymous said...

I had tons of checks, unfortunately! I started having contractions on a Saturday night and had them regularly until my son was born on Sunday night..,8 days later. They checked me several times Monday when I went in with contractions 3-5 minutes apart, only to discover I was dilated to 0. They sent me home & told me not to come back unless my water broke or I hurt a whole lot more. Then they checked me at the Ob-Gyn appt. Thurs when I was finally dilated to 1. Saturday my water broke & I went in to the hospital around midnight. They checked me every couple of hours. A nurse "stretched things out a little" and got me to 7 by 3 am, but I never got beyond that and they eventually did a c-section. It hurt like heck everytime and was depressing to know I wasn't making any progress. I wish I would've been more assertive requesting fewer or no exams, as studies have shown infection is caused by the checks, not just because your water is broken.

Rachel said...

As a L&D nurse, I have come to learn that checks don't tell me anything about where a women is going to be, even within 10m. And I hate telling women how far dilated they are. Unfortunately, that is the only sign of progress we can get with women who have epidurals, therefore, it has become standard practice.

I do think there are instances where they are useful, sometimes you can discern the position of a baby and help position the mom better to change it's position(sometimes moms are able to do this on their own though). It also helps sometimes in a case like yours where there is just a tight cervix in one spot or a small lip that is holding baby back.

For me, though, there is no reason to use them to tell where the mom is going to be. It's very unreliable.

Just a note on them hurting. I had one lady ask me why it hurt so much for the other nurse to check her and it didn't hurt when I did. I just shrugged my shoulders. But I do know that I was being particularly careful when I did her exams. I think practitioners tend to forget that we are dealing with a woman's body here and not just an outlet for the baby. Perhaps, we can make those exams more comfortable if we try.

LauraB said...

I've always like the expression "If God meant for the cervix to be fiddled with, He would have put it on the outside."

just said...

As a midwife, when I am practicing (which isn't often), I try not to do any vaginal exams, and more often than not I am the one telling the mom that, no, she doesn't need a check. Everyone expects it, though. I always say that I will do one if I feel like it is necessary to get more information about the baby's position (by feeling suture positioning) or if the labor was simply baffling us for some reason or if there were signs of fetal distress. Otherwise, my best indicator of labor progress (and I've gotten quite good at ascertaining this way) is to listen to the noises the mom makes. The last two births I went to I did no vag exams. For one, I wasn't even in the room when the baby was born, and for the second, I visibly identified protruding membranes when the mom asked me what she was feeling between her legs. The membranes protruded for HOURS before the baby was born. She was in the tub most of the time, and the only way I knew the baby was coming (since I couldn't see and she had been pushing for hours) was to gently put my hand alongside her vulva during a push just to determine if the head was crowning. And then, out the baby came! Birth is nice that way. :)

Amy Hourigan said...

During my first labour I was FORCED to have a vaginal check and it was very distressing. I heard things like 'Your only 5cms' which was soul destroying... needless to say cascade of intervention ended in caesarean.

2nd Birth I have a VBAC and refused all offers of vaginal exams, right up until I hit a wall and felt like baby was stuck (anterior lip).

Cervix checks can be very disappointing and can cause women to give up. Hearing things like 'Your only 5cms' can send a woman straight to epidural land.

Betsy B. Honest said...

Interesting post. I've always found the cervical checks to be not painful and very helpful to assure me that labour is progressing. I can't imagine skipping them.

Betsy B. Honest said...

Interesting post. I've always found the cervical checks to be not painful and very helpful to assure me that labour is progressing. I can't imagine skipping them.

amy friend said...

One glimpse into my hospital birth experience: nurse does cervical check, dr. comes in 20 minutes later, and MUST do cervical check....shift change occurs 30 minutes later, and new dr. MUST do another cervical check "for her records". Hopefully my experience was rare...because this was the least of the abuse!

Anonymous said...

With my first hospital birth I had numerous pelvic exams which I found painful and very discouraging. With my 2nd birth (at home) I had none. This was partly because my midwife did not consider them routine, but also because bub came quickly before the midwife even arrived! It was awesome to be able to just go with my body and push when I felt like it. Now that home birth might be off the cards for me next time (being Australian), if I have to go to hospital again I'll refuse them.

Sara said...

I don't mind the checks, especially when my body starts pushing, but I have requested not to hear the result as I feel it can really hinder a woman to hear, "you're still only 5cm!"

Anonymous said...

I didn't have checks during my labor (accidental home birth), but I have a feeling that if I did it would have gone similarly. My labor was 33 hours and there was a TON of counter pressure involved too. Peanut had been "sunny side up" for weeks and the midwife told me she flipped at our last appointment. Either she didn't really flip (I was literally seeing a new midwife every week trying to meet all the ones that could deliver my baby, ironically in hindsight, so it goes back to the "everyone feels things differently" thing) or she flipped back around. Either way I'm sure that she was posterior in labor.

Anyway, I had that same feeling that you did. Suddenly going from nothing to "holy crap I have to push RIGHT NOW" and I think it was because she flipped.

Lauren Wayne said... Isn't that strange, how the labor can just turn like that? There was much confusion over Mikko's position in the womb, too, which made me wonder just how much is guesswork anyhow.

On a similar subject, I thought this article on Midwife Thinking was really interesting, that pushing before being fully dilated can be completely valid if the woman has the urge, particularly if the baby is posterior and needs to adjust positions.

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