Cervical checks and heartrate montior necessary?

[Friendlee]

I am not pregnant yet, but during my last labor, I had what seemed like a lot of cervical checks (probably just the minimum) and was attached to the monitor every hour and a half. For me, both of these things were painful and miserable as I had to position myself and lift my hips etc.

I'm just wondering....why exactly do I need to be checked? Obviously there's the curiosity of how dilated I am, but if I can stand to not know, is there a reason I must be checked? Anyone have experience rejecting this in a hospital and what sort of issues did you run into?

Also, I'd love to hear others' stories about refusing or significantly limiting the monitoring in a standard hospital (which is where I will labor next time too). I requested minimal checks in my birth plan but I don't know what normal is.

[erin_brycesmom]

IMO cervical checks are completely unnecessary and have significant downfalls. It's going to be hard to refuse them alltogether in the hospital because they usually won't admit unless you are Xcm but I suppose if you go in pushing they won't have time. Other than that, they will likely want to check you before allowing pushing but I would just say no. If the hospital/dr/staff are reasonable, then this should be fine. If your labor becomes prolonged then I believe it will be a hard fight on that one. I had several checks during my hospital birth even though I had planned to decline them. I just didn't have the energy to fight them on it. With my homebirth, I had zero cervical checks during the entire three day labor and I loved that!!!!

As far as the monitoring went, I lucked out with my hospital birth as they were great about that. They used the handheld doppler two or three times throughout the entire labor and pushing and that was it. I just told them when I got there that I wanted intermittent one on one that way and they said sure. This is not a progressive hospital at all, lol. Good luck mama .

[katelove]

I think both can be useful tools if used correctly and that both a significantly overused.

In Australia there is a flowchart published by RANZCOG to guide the use of continuous foetal montoring. It isn't too bad considering the source IMO. ACOG probably has one too that you could look at to see if you met any of their criteria. If you don't you then have a good argument for anyone who wants to monitor anyway. If you do meet any of their criteria you could then do some more research to see if you felt the reasoning was valid.


In terms of cervical checks (and CFM really) I would ask the usual questions - what information do you want? Why/what will be done based on the information? Is there another way to get the information? What if we do nothing?

On a personal note, I have written my birth plan assuming that I wil remain low risk (if that changes I will do another one). In it I decline CFM and routine cervical checks. In my mind (I haven't written this on the plan) I am probably happy to compromise with a check on arrival to confirm that I am in active labour. However if, at the time, this just seems like it would be too stressful then I will decline it. I will also request one if I feel like I need to know where I am for my own psychological benefit.

I think it can be really hard for women to make decisions they'll be happy with later while in labour so my advice to people is to be very clear in your mind beforehand what you will consent to in what circumstances. Which you're clearly doing by asking the question so you obviously don't need me to tell you that. Ok, rambling now. I'll stop but the first two paragraphs are my thoughts on the matter.

ETA - Actually I just had a look and it seems like the ACOG guidelines are only aavailable to members. You should be able to download a PDF of the RANZCOG guidelines from here http://www.ranzcog.edu.au/publicatio...lth.shtml#IFSG
Probably won't carry much weight with a US OB but it will give you a place to start.

[MegBoz]

Originally Posted by katelove

In Australia there is a flowchart published by RANZCOG to guide the use of continuous foetal montoring. It isn't too bad considering the source IMO. ACOG probably has one too that you could look at to see if you met any of their criteria.

Nope. I'm pretty sure I read that ACOG says intermittent monitoring, for low-risk births is just as good as continuous. But they do NOT recommend against continuous monitoring!! Whereas the Canadian OB/GYN organization does recommend intermittent as preferable to continuous for low-risk birth (and, as we all know, that is the evidence-based recommendation! Since cEFM for low-risks births does nothing but increase intervention rate without any improvement in outcomes.)
BTW, it was probably in "Thinking Woman's Guide to a Better Birth" that I read that. Otherwise, perhaps "Born in the USA."

In my own experience, the nurse at Johns Hopkins gasped when I mentioned intermittent monitoring. "Oh, no, we need to be able to 'see' your baby!" And this is a hospital that is continually ranked as one of the best in the nation by US News & World Report! Just goes to show you - the best hospital (place for sick people!) is NOT the best place for birthing mamas! I switched to a smaller hospital outside the city that is much more mama & baby friendly.

In any case, I totally agree with what erin_brycesmom wrote.

I had in my birth plan that I'd consent to a cervical check before admission to ensure I'm in labor & I'd consent to another one to ensure dilation is complete before pushing, but beyond that, I don't want any & would rather not know how far along I am. My MWs (CNMs) were cool with that. Of course, had I been in that hospital laboring along for 8 or more hours, I'm willing to bet they would have asked anyway... at least one of the 3 of them.

As for avoiding both of these things, hopefully your hospital has a tub you can labor in! In that case, you can't possibly be hooked up to an EFM machine for long - they'll have to use a doppler. So look for a hospital with a tub & get in!

[crunchy_mommy]

Well... I'll try to briefly sum up my personal experience & try to keep the emotion out of it...

I refused cervical checks throughout pregnancy & labor. To be more accurate, a few times I let them attempt to do an exam but did not allow them to complete it (I have a history of sexual abuse & just couldn't handle it). Was admitted once for possible pre-term labor (turned out to be some infection) and the doc insisted on doing an exam against my wishes.

When I was finally truly in labor no one believed me (because I wasn't screaming in pain?!?! I don't know why they didn't believe me, I knew for a fact I was in labor, just like the "pre-term labor" scare I knew was just a bad backache)... ANYWAY so they could not do any successful cervical exams but I was having prodromal labor (which I attribute to the stress of repeated attempted cervical exams!!) however I wanted to stay in the hospital because I wanted to labor in the shower and our water at home was shut off due to construction on the water main. Lucky me. So after spending almost 24 hours in the hospital & about 35 hours in labor, my choices were to go home (and likely end up back at the hospital within several hours, I knew we were getting closer to push time), labor without water etc. OR I could stay in the hospital but I'd need an epidural so they could check me. I was exhausted at that point & had bad back labor, so I consented (against my better instincts) to the epidural. They checked me & I was at 6cm. Well they wanted to make sure the baby was born soon because of the epidural? I don't understand this part, maybe there were more risks to him if I had the epi & then didn't deliver him for another 24+ hours? Either way, I didn't really have a choice in the matter, they broke my water & started pitocin without my consent. Hours later DS was born with vacuum assist (I was pushing well but his heartrate was dropping too much). I narrowly avoided a c-section & overall his birth was very traumatic for me. Oh, I had intermittent fetal monitoring throughout labor. It would have been fine if the nurse actually came back within 20 minutes to remove the monitors like she said she would, but she'd always end up coming back a good hour later and all that time I'd be writhing in pain in the bed, unable to walk or shower through the contractions. A few times I tried refusing the monitoring but I just got yelled at repeatedly so I just gave in to it.

Needless to say, I am definitely looking into other options for when we conceive #2. I would like to refuse all cervical checks and have only very limited monitoring & I'd probably just take the monitors off myself if the nurse didn't come back!

[kltroy]

monitoring is bsaically a convenience, as it allows them to centralize all the fetal heartrate data at the nurses station. So they can employ fewer nurses for more moms. cervical checks are done mostly because doctors are impatient. you can always refuse. it may be useful to have one if you're feeling pushy, just to make sure there's no lip in the way that can get swollen. and sometimes YOU may want to know... for example, if things are getting tough and you're wondering how much longer there is to go, it can be encouraging to know that you're at 8-9 cm. OTOH, it can also be very discouraging, if it's tough and you're only at 5 cm!!

[erin_brycesmom]

There is no reason to worry about a swelling lip if you wait until your body pushes with an uncontrollable urge which is what I would recommend any how unless there was some kind of emergency. So don't think you have to be checked before pushing for fear of swelling because that's a myth .

[MegBoz]

Originally Posted by erin_brycesmom

There is no reason to worry about a swelling lip if you wait until your body pushes with an uncontrollable urge which is what I would recommend any how unless there was some kind of emergency. So don't think you have to be checked before pushing for fear of swelling because that's a myth .

Yes, I thought the same thing! I WANTED to be checked because I'd heard horror stories of pushing on a lip, swelling, needing an epidural to fix, etc.!! Of course, it's rather silly in hindsight, that it didn't occur to me to question this! (FOR ME personally, I wanted & needed that VE to confirm, but now I know differently.)

Anyway, someone posted some great info on cervical lips - may have been HB forum - articles written by MWs, really interesting stuff! Basically, they said that even if you DO push at 8 CM, if you're listening to your body, working with natural urges, it's not necessarily going to lead to a swollen lip & not going to impede complete dilation.

[Fyrestorm]

Originally Posted by erin_brycesmom

There is no reason to worry about a swelling lip if you wait until your body pushes with an uncontrollable urge which is what I would recommend any how unless there was some kind of emergency. So don't think you have to be checked before pushing for fear of swelling because that's a myth .

Not so much..I had uncontrollable pushing contractions at 6 cm. I swelled back down to 4 by the time I transferred to the hospital. She was posterior, that may have had something to do with it though.

[erin_brycesmom]

I can't speak to someone's personal experience since I wasn't there, don't know what all went on, etc but I have studied it and over and over again, the studies show that there is no harm in pushing with an uncontrollable urge regardless of cervical dilation or being "checked" first. I don't have my references on hand as it's been a while but I remember this post where a MW listed a bunch of sources - http://www.mothering.com/discussions...2&postcount=24

I mean really though, what is one to do when they have an uncontrollable urge? If it's truly "uncontrollable" then there is nothing you can do about it and being checked won't help. And even if there is some fluke that causes you to swell, being checked won't change that. There are plenty of women that get the ok to push at 10cm and still swell because their body isn't ready. I believe in pushing when my body tells me to and I don't think it will stray me wrong in that situation as long as I'm letting my body lead the way including taking a body led stance for birth. IMO, one of the worst things a laboring mother can do is try not to push when she has the urge. The worst tears almost always occur in that situation IME.

I "had" to have my provider hold back my lip with my 2nd while I pushed past it. Talk about torture. Looking back, I believe that was totally unnecessary. I have no idea how far I was ever dilated during labor with my third, lol. It was great. Pushing was by far the easiest despite my baby being 9.5lbs with a 15 inch head and a nuchal arm - yikes! Less than 4 minutes and no tears. No one else's hands on me or him while his head came out and my body was completely leading the way. I was just along for the ride. No recovery at all which is a miracle considering the long awful recoveries I had with my first two.

A great article from Midwifery Today, The "Rule of 10" Versus Women’s Primal Wisdom - http://www.midwiferytoday.com/articles/RuleOf10.asp

[erin_brycesmom]

Originally Posted by Fyrestorm

Not so much..I had uncontrollable pushing contractions at 6 cm. I swelled back down to 4 by the time I transferred to the hospital. She was posterior, that may have had something to do with it though.

I just wanted to clarify that I'm talking about pushing with an uncontrollable urge not just having pushing contractions. I'm pretty sure I've read your story before and you fought the urge to push precisely because your cervix was checked, right?

[Fyrestorm]

Originally Posted by erin_brycesmom

I just wanted to clarify that I'm talking about pushing with an uncontrollable urge not just having pushing contractions. I'm pretty sure I've read your story before and you fought the urge to push precisely because your cervix was checked, right?

Yes...I fought them for hours! I allowed a check because it had been so long...we were really hoping this was it.

[dannic]

My first birth at a bc was with a cnm and she insisted on checking me every hr. It never occurred to me to refuse--they were so painful!

My last was a hb and I was never checked. I was totally in control and it was amazing how easy it is to listen to your body when others are respecting it/you. GL and stand strong. Would it help to have a doula?

[Turquesa]

Here is an extremely revealing piece addressing the OPs questions. It contains tips on how to avoid a lawsuit.

According to ACOG clinical guidelines, documentation of ongoing fetal assessment throughout labor is mandatory.14 In the US, the vast majority of patients in labor have continuous electronic fetal monitoring (EFM) for multiple reasons, including patient and physician preference, efficient utilization of nursing personnel, and medico-legal documentation. Intermittent auscultation is a reasonable alternative in selected low-risk patients.14

Notice that there is no mention of concern for evidence-based practice--just preference, short-staffing, and CYA purposes.

Study after study shows that monitoring by Doppler or fetoscope is much more effective. (Electronic fetal monitoring has a much higher rate of "false positives," or incorrect readings of fetal distress).

Now check out this little gem:

Digital cervical examinations are necessary to determine how labor is progressing. Too infrequent examinations can delay recognition and treatment of inadequate progress.

Inadequate based on what, I ask?? Based on the mentality of "active management," a protocol of mainstream obstetrics that critics consider quite controversial.

Long story short: The cervical checks and routine, continuous fetal monitoring have everything to do with the self-interests of doctors and hospitals and little to do with you.

We now know that malpractice considerations are based substantially more on fear than on reality, but the today's medical mentality sadly calls for treating every patient as a potential plaintiff.

[MegBoz]

Originally Posted by Turquesa

Here is an extremely revealing piece addressing the OPs questions. It contains tips on how to avoid a lawsuit.

EXCELLENT post! Great info!!

I like how another reason for cEFM includes patient preference. Well, yeah, if the OB tells you your baby could be at serious risk if you take the monitor off and baby could die during the torturous, brutal, dangerous ride that is labor, then of course you're going to prefer having the monitor on!

Regarding "inadequate progress," I love how in the movie "Orgasmic Birth" they showed one natural birth after another (mostly HB) & showed the number of hours the birth lasted. Quite a few were more than 24 hours long. Then they kept contrasting that with hospital births where they were pushing pit & even vacuum after less than half the time.

[crunchy_mommy]

Originally Posted by erin_brycesmom

No one else's hands on me or him while his head came out and my body was completely leading the way. I was just along for the ride. No recovery at all which is a miracle considering the long awful recoveries I had with my first two.

That sounds so wonderful!!! What a contrast from my own DS's birth, me practically screaming at the OB that I didn't want her hands inside me and her practically screaming at me that she HAD to do what she was doing. I didn't (still don't) feel like I "gave birth" but more like she pulled my child out of me. It was very traumatic for it to happen that way (not to mention the several MONTHS of physical recovery!)

I'm really interested by the research being referenced on this thread! I thought the only options were to allow the cervical checks or to learn to do them myself (only a marginally more appealing option!)