... should seem straightforward enough, but as I continue looking at the why's of doing midwifery, I have gotten much more judicious in putting my hands inside women and touching their bodies.
Unless there is a medical indication, I don't do a Pap in pregnancy. In midwifery school, I did Paps on women throughout their pregnancies, up to and including in early labor. The more pregnant the woman was, the more she bled because of her very vascular cervix. Early in my learning, I thought I'd caused a miscarriage (or dislodged a placenta previa) in a woman 24 weeks along who bled so much she filled a chux pad. Showing my preceptor, she looked at the woman's cervix and explained the friability of some cervices and the capacity for bleeding so much it can be frightening. I kept listening to the baby for another hour or so and had the mom come back the next day to listen again - the baby was fine and she went to full term and delivered perfectly fine.
We are a product of our experiences.
If there is a history of abnormal Paps, HPV, HSV, cancer in the family or if the mom wants one, I do one - otherwise, I wait until 3 months postpartum.
Doing a Pap in pregnancy is part of the Oh-Look-the-Woman-Is-Getting-Care-Let's-Get-Every-Test-We-Can-Done-In-Case-We-Don't-See-Her-Again mindset. If I am sure I will see a woman, I feel comfortable waiting until she isn't pregnant to do one.
So, what of vaginal exams? I've written copiously about my changing from routine exams to doing them for a real reason - curiosity and just-because don't count as real reasons.
Therefore, this morning, finding myself driving to a client's home, I re-hashed how I would approach doing a vaginal exam on her.
Mom is a G2P1 and 41.1 weeks. Her first baby was born at 39 weeks, but, for reasons unknown, she had been stripped (twice) and provoked with homeopathics and she took 15 hours to get from 1 to 4cm - transferred to the hospital at 4cm and had another 20 or so hours with an epidural and pitocin. In good spirits, she has had contractions pretty much non-stop for a week or so... copious mucous ("gloppies" as my family calls it), but no bloody show yet, she is ready to have the baby. Today she used the word "exhausted" and I explored with her how she would feel if she went into labor feeling exhausted. She said she could do it because she would know there was an end in sight. She is very motivated this time to birth at home. I don't believe pain will be a reason we transfer if we have to go in.
I leave for New Orleans in 6 days. Mom will be 42 weeks the day I leave.
While I would tend to her past that day as long as the baby continues doing well (I would either send her in for NSTs every 3 days starting in a couple of days) or do an NST in her living room. We homebirth midwives do NSTs by having mom pee, get a glass of juice or soda and sit in a comfy position. I work around her... if she's on a chair, I sit on the floor. She's on the bed, I sit on a chair. And then I listen and have someone chart for me the times I call out. I count fetal movements for 10-15 minutes or at least 10 movements - whichever comes last. If all is well, I see mom in 2-3 days to repeat the NST. She always has the opportunity to go in and have a standard NST. Most choose not to do so unless they are involved with obstetric/midwifery co-care.
So, while I would tend to her past 42 weeks as long as all is well (the number of days past 42 weeks isn't a solid, but would be judged by Biophysical Profiles every 2-3 days and re-evaluating sonos, dates, length of mentrual cycle, and mom's wishes) - I don't think I could find another midwife who would want to jump in and take care of a mom she didn't know who happened to be past 42 weeks.
Do I do something to provoke this labor? (The word in Spanish is provocar - to bring on - it's a great, great word not used often enough in English birth terms.) Or do I remain in a place of believing the baby will come when she's ready (it's a girl). Do I do an exam on a mom with loads of gloppies, knowing she is making changes, but wanting to know exactly what kind of changes are being made?
Sitting with mom this morning, I know my words can sway her either way. I can stand firm and tell her I know all is fine and her body is perfect and we can wait. She asks about how long we can wait. She says she isn't comfortable going past 42 weeks. I remind her I am leaving on Monday. She remembers. I know I could suggest a vaginal exam and she would jump at it despite saying she wanted to forego them earlier in the pregnancy. While the woman always has the ultimate choice, I am well aware that my voice, words, posture and tone all come into play. Sometimes I wish I could type or write them a note.
Looking at me expectantly, I asked: Do you think you want an exam? Her immediate answer was an emphatic YES. I looked at her and asked if she also wanted to be stripped and she said she thought I'd never offer. Yes!
I'd done it. I'd said the words, swayed the energy, influenced a decision, changed the course of a normal pregnancy and early labor. Does my knowing this and feeling like crap about some of it make it better? I doubt it.
We talked at length about what stripping membranes entails. She remembered from last time, but I wanted to hear her acknowledge that I could stir a lot of nothing up and make contractions hurt more even if they remained (technically) unproductive. She said she really didn't care about her dilation - and had been checking herself anyway ("a couple of fingers, I think") - but really wanted to have the baby with as few medical interventions as possible. We talked about the variety of paths towards induction... natural and medical... and she said she is opting for the natural at this time. We talked about what was next after this and I said another stripping tomorrow morning and then castor oil a day or two after that. (Sex, walking, homeopathics, nipple stimulation, etc. have all been discussed for a couple of weeks now.) She said she was game. I reminded her that if at any time the baby doesn't tolerate these things, plans will change. She said she understood. (See why I do narrative charting?)
We go up to her room and do the standard checks... all is well... baby is active and her heart tones are lovely. Before the exam, I tell mom it might be very uncomfortable - or it might really hurt. I tell her to hold my hand and squeeze it as hard as she wants to and to feel free to tell me to stop if she needs to catch her breath or to get out if she wants the exam to stop. I tell her I will honor whatever she needs me to do. I then begin the vaginal exam, as always, asking permission to touch, telling her I am going to touch and then moving in and finding her cervix easily, slightly to my left, but anterior. She is at least 4cm/60%/0 - and ecstatic! She was 4 when she transported last time; she has already gone to that point and is at home. I chuckle and tell her she said the dilation didn't matter... she laughed and said, "it didn't until now!"
I then feel the head, her positioning is great... ROA to OA, deep in the pelvis and not ballotable. I didn't feel a bulging bag (which is neither good nor bad). I then began the "stripping" - an odd term considering it is more a stretching and pulling of the cervix as opposed to stripping anything. The term comes from pulling the membranes off the uterine wall to stimulate prostaglandins. Pulling the cervix does the same thing (hypothetically).
I tuck my two fingers under the lip (I do not mean an anterior lip) of the cervix and slide them around the mouth of the cervix... more able to reach the anterior underside than the posterior underside. I can easily put my fingers in up to my first knuckles. I held her hand, she barely squeezed it, and moved around and around, in a semi-circle, back and forth, about 8-10 times. I reached as far back as I could a couple of times - the baby's head never dislodging (a great thing!) and as I left, I brought out some bloody show. Not a lot, but at least some. I was taught if you didn't get blood, you didn't do a good enough job stripping.
Mom is doing well this afternoon. No extra anything at this point... just the usual contractions like the past few days. I wonder if I'll hear from her tonight.
Those of you who have this power to influence... how do you wield it? How do you weigh the words and expressions so the mom really does get to make the ultimate decision yet you are offering the range of possible options?
Reading this, does this sound like I am a medwife? Do I need to look at this more than I have? I trust you all will help me know the truth.
Thanks for listening.