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Tuesday
Jun062006

Doing a Vaginal Exam...

... 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.

Reader Comments (8)

I went to 42 weeks, 2 days and practically begged my MW to check me and strip my membranes. I had not been having many contractions, not even many BH ctx, and I was desperate. At that point I looked at it as, I do not want to be risked out of my homebirth and if having my membranes stripped will get things moving, then bring it on. I was really past caring about not wanting to have a vaginal exam during pregnancy. I loved and trusted my midwife totally, and what she did sounded very much like what you described...very gentle, telling me every step of the way what she was doing. And the progress she reported energized me, reassured me that yes, this baby would really come out, and soon. And he did, the next morning (twelve lbs two oz, born in the bed where he was conceived). I enjoyed reading this entry...it brought back a lot of good memories.

June 6, 2006 | Unregistered CommenterKayla

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.

Barb,

I'm somewhat surprised to hear you asking a question like this- looking for validation in this way! Do you not KNOW? You already have the answer- you and I both know you know. You can't go into something with such high awareness, such clear intention, and fuck it up. I tell my clients this very thing and I will *remind* you (because you already know!), that you can't screw up. This mama was waiting for you to say something, she was 'ripe' in more than just her cervix, and you were there at just the right time when she was open and yeilding to receive you.

It isn't wrong to ask a question when you take responsibility for the answer, for the results.

'Navelgazing Midwife' and 'Medwife' do not belong in the same story together, much less the same sentence.

June 6, 2006 | Unregistered CommenterKristina

I don't do exams often--
reasons to do exams- like what you did today- what is her Bishop's score? pretty decent tool
http://www.mother-care.ca/bishop.htm
gives you a hint on the likelihood if an induction attempt will be successful.

other reasons to do an exam-- figure out presenting part incase it is questionable from the top

atleast take one good look at the vagina before birth incase you need to sew back up--

check/rule out infection infection - dx type of infection

to have more information than you have now- that can change how you care for a client

because a mother wants one done--if this makes her feel better or safer-- why not. I usually will put off exams a bit because I think you can carry infection from the outside up and will refuse to do an exam if ROM until many hours down the road and we are sure that active labor has been established. I prefer to not "check" just before pushing- I wait and women who have effective pushing start out with a few grunts and then wam-- and women who will do grunts that don't seem to move into that intense pushing we get them moving around and assess position - could be baby needs to have some extra pressure to encourage turning or movement of some kind---
some women feel invaded and some feel like they have finally been treated properly-- you have physical information even if it can change in the next few minutes/hours... I noticed this as something that even women who do UCs report doing-- and I remember doing my own checks while laboring as well.

so for irritable uterus that keeps sleep at bay--hydration -- and belly banding- that funnel will often either get things moving along faster by helping to keep the baby's body lined up and head applied better or it could stop the irritation from a folded over uterus--

June 6, 2006 | Unregistered CommenterAnonymous

Kayla: Thanks for that. I am amazed at the size of your child!! YOU GO GIRL! Thanks for the comment about good memories. The last thing I wanted to do was create another situation for this mom like what happened last time.

Kristina: If I was sure I wouldn't ask! Thank you for your input, too, though. I know I have been told that it is in my wondering that I am conscious - not just doing it because the vagina is there and waiting to be examined.

I don't know if I worded it all right, though. I think I wonder how others feel or cope with the manipulation of the energy of offering choices to mom.

To expound: One midwife I knew didn't know how to do IVs, so when she counseled about GBS issues in labor, she poo poo'd the idea that antibiotics did anything. Her clients, therefore, rarely, if ever, asked for abx in labor. Other midwives I've known do the same thing - with Newborn Screening (PKU), Vit K, E-mycin, etc. Obviously, I do the same thing, too, with Paps and STI testing in pregnancy.

So, how do others do this? How do you justify it? (Like I did regarding the Pap.)

Maybe that is more what I mean.

Anon:

Thanks so much for sharing why you do vaginal exams, too. I love hearing how others do things... not enough of us talk about it. I really agree with your reasons, too. I do them for similar reasons and can't recall the last time I checked a woman before pushing. It had to have been in 2003 at a Texas birth center.

It's been suffocatingly hot here, so I had checked in with mom several times regarding fluid intake. She looks marvelous - no swelling whatsoever, supple, pliable skin tone, and very mobile (not sluggish at all). She also has belly tone I wish I'd have had at 12 years old! I have suggested warm baths several times (she has a great giant in-bathroom tub) and camomille tea, meditation, etc. She said her uterus just wakes her long enough to go pee and then she goes back to sleep for a couple of hours. She feels the interrupt sleep is worse than anything even as she is able to sleep 8+ hours combined.

I smiled when she said being with a newborn will be easier than the contractions. I'll remind her of that in a few days.

Thanks so, so much for your input. It really is great to hear your reasons... very helpful.

June 7, 2006 | Unregistered CommenterNavelgazing Midwife

Reading the story, I truly believe you felt the woman's energy/desire to be asked about being checked, and that's why you brought it up.

You DIDN'T do it because you were calendar counting. I think that's really why you are worried about having done the check/stripping.

Don't question your intentions. From your post it is abundantly clear that you are still focused completely on your California mama, not on your New Orleans mama (who, by the way is moi).

June 7, 2006 | Unregistered CommenterBarb in NOLA

tt I think you did something reasonable
I wanted to say that just to be clear, incase I wasn't clear enough earlier.

now I am going to appear as a prat-- why you don't write a narrative --- this does not read much like medical information- I enjoy the story here on the net but why do we keep records? for clients to remember what we have done from one time to the next- also because it is often required by a license- and to document incase there is a problem in the future- --

now what would the shortest form of this information look like?
you have a protocol already for when to start NSTs -
the language about constant contracting -exhaustion and her at 4 cms could be misconstrued in a chart- mother reports "braxton hicks contractions and copious amounts of mucous discharge " why would I say braxton hicks? because these are short non-labor contractions and she is able to sleep through them it is a commonly understood term
----justifying to anyone else who reads the chart why you did an exam is almost pointless - the mucous or dates alone could point to a need gather more information.-----
discussed with client risk/benefit of stripping membranes
I ask --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!

exam reveals - 4cm/60%/0
report that you stripped membranes and blood tinged gloves - BOW in tact
discussed comfort and coping measures
if no labor will be seen for next NST in 3-4 days

needs to be shorter than this but still has some flavor of a narrative and gives information- preference would be a check sheet on a form- with small notes on the bottom that show - her reports and desire to be checked/stripped.

June 7, 2006 | Unregistered CommenterAnonymous

As an emphatic "do no interventions" type of mama... I BEGGED my midwife to come on Monday and strip my membranes with my last child... I was so tired, so very tired of being pregnant... She laughed and threw the "no interventions I'm a vbac mom" at me, before telling me she'd try and be by on her way home. She did it on Thursday. Only after chatting with me for almost 45 minutes about it first. It was almost as if she needed to make me defend it... not a bad idea with me as a client!
I got some good contractions going by the end of the night, had daughter the next night. After I once again begged for an intervention, breaking my membranes. But that is another story, this looking back in hindsight is a good and bad thing some days.
I do not think that you will look back on this post and feel bad about what you AND your client (sounds like she knew what she was agreeing to!) added to her birthing journey.
Looking forward to her story, if she gives permission =)
k

June 7, 2006 | Unregistered Commentermm

"Reading this, does this sound like I am a medwife?"

Yes, yes and YES! Just b/c the mom might have wanted this doesn't mean it was the right thing to do! Your offer absolutely did influence her.

Women are ever so conditioned in our culture to believe that they can't get through a pregnancy and birth without some type of intervention. The stories are all around us - on tv, from family/friends, in books, in the news...

How about being part of the world where women are telling their friends "My midwife reminded me my body knows just what it's doing. It will tell me when it's time to birth my baby. My body is perfectly designed for birth, and she doesn't/I don't need to do anything to try to nudge it along."

What you did simply contributes to womens distrust of their bodies and the birthing process, whether your client wanted it or not.

October 16, 2006 | Unregistered CommenterAnonymous

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