vaginal exam when ready to push REALLY necessary?

[caedmyn]

I prefer hands-off births, but I know a lot of homebirth midwives like to do a vaginal exam when mom feels the urge to push to make sure she's fully dilated and there's not a cervical lip or something. I feel like this is probably unnecessary in most cases, but I'd like some opinions on it. If there was a cervical lip impeding progress, is it something that's likely to spontanteously resolve or become evident fairly quickly, rendering a VE unnecessary without an indication of need for it? FWIW I've had pretty short pushing stages with both my births, 20 min. with my first and maybe 5 with my second. So I would think if I've pushed for 5-6 contractions and baby's not coming, it might be an indication of something holding up progress, but I'm not an expert.

[harli]

IME they cause more harm then good. When I labor I feel the urge to push around 6 or 7 cm's. The first birth I had an epidural shortly after I hit 7 cm's so I don't know what would have naturally occurred after that (ds was born only 20 min's later). With my second I hit 6 cm's and felt the urge to push, we then called the nurse in. The nurse came in and checked me and told me condescendingly that it couldn't possibly be time to push yet since I'm only 6 cm's and that it was only wishful thinking on my part. Well I quickly found out that it HURT to not push, so I did without them there. I delivered dd 13 min's later with the doc's and nurses rushing in at the last min. causing a whole big commotion after she was half way out. If they would have listened to me rather then an unpredictable thing like a VE then maybe I would have had some support. As it was I was pretty much all by myself and pretty scared. (DH was there but watching T.V since the nurse had said we had a least an hour or two yet )

While I do think there are exceptions I think you would be hard pressed to find a women who pushes so hard before she is fully dilated that she hurts herself. Maybe the better option would be to decline a VE when you feel the urge to push and then if things are moving slowly allow a VE to make sure there isn't a cervical lip or something.

[MsBlack]

No, I don't feel they are needed, and usually don't do them unless a mom really wants me to. If she asks me--'do I need you to check me first?', I say I don't think so, that she can trust and work with the sensations she's having.

When a mom tells me she needs to push, and I am not sure myself if it's really time (from various signs I observe), then generally I will ask her to really follow her body...my mantra is 'breathe when you can, push when you must'...if you don't force things by immediately holding your breath and bearing down with all your might, you're not going to hurt yourself! You might well come to involuntarily holding breath and bearing down--but if you do this by following your body's demands (rather than applying human 'rules of pushing'), you will be just fine.

And I've never seen a swollen anterior lip that prevents progress, never saw a mom hurt herself if she is following her body's own signals as they arise. Birth occurs from the inside...and most often, moms don't need outsiders telling them what to do!

[Twinklefae]

Originally Posted by harli

IME they cause more harm then good. When I labor I feel the urge to push around 6 or 7 cm's. The first birth I had an epidural shortly after I hit 7 cm's so I don't know what would have naturally occurred after that (ds was born only 20 min's later). With my second I hit 6 cm's and felt the urge to push, we then called the nurse in. The nurse came in and checked me and told me condescendingly that it couldn't possibly be time to push yet since I'm only 6 cm's and that it was only wishful thinking on my part. Well I quickly found out that it HURT to not push, so I did without them there. I delivered dd 13 min's later with the doc's and nurses rushing in at the last min. causing a whole big commotion after she was half way out. If they would have listened to me rather then an unpredictable thing like a VE then maybe I would have had some support. As it was I was pretty much all by myself and pretty scared. (DH was there but watching T.V since the nurse had said we had a least an hour or two yet )

While I do think there are exceptions I think you would be hard pressed to find a women who pushes so hard before she is fully dilated that she hurts herself. Maybe the better option would be to decline a VE when you feel the urge to push and then if things are moving slowly allow a VE to make sure there isn't a cervical lip or something.

The thing about that, is that you could have done yourself some serious damage, pushing before you were fully dilated. I had the urge to push starting at 4 cm. No one was condescending (thank goodness - I would have reported a nurse who was rude to me!) but the uncontrollable urge to push gradually started swelling my cervix. If we hadn't been checking it, and monitoring it, we wouldn't have known to get me an epidural, which stopped me from pushing, allowed my cervix to return to normal and saved my vaginal birth.

I would never birth with someone who said that they didn't find them necessary.

[prothyraia]

I didn't have one. I got a VE when she first arrived, and that was it (of course the baby arrived 2 hours after she did, so....).

[harli]

Originally Posted by Twinklefae

The thing about that, is that you could have done yourself some serious damage, pushing before you were fully dilated. I had the urge to push starting at 4 cm. No one was condescending (thank goodness - I would have reported a nurse who was rude to me!) but the uncontrollable urge to push gradually started swelling my cervix. If we hadn't been checking it, and monitoring it, we wouldn't have known to get me an epidural, which stopped me from pushing, allowed my cervix to return to normal and saved my vaginal birth.

I would never birth with someone who said that they didn't find them necessary.

As I stated in my post I wasn't full on pushing they were small little grunty type pushes. If I didn't push it hurt so I only pushed so hard as to not make it hurt. I'm sure that if I pushed hard enough that it was causing damage to my cervix it would have hurt more then not pushing. For me it wasn't an uncontrollable urge (until the last two pushes), it was merely what I had to do to stay comfortable. You'll find that many natural birth professionals will say that the little grunty pushes don't hurt anything. I'm sure there are exceptions to that, maybe you are one of them, but most of the time, if left to their own devices, a women won't damage her cervix by pushing too soon.

I really believe that my body, at least in this case, knew what it was doing and that pushing when I did is what allowed me such a quick easy delivery.

[AnneCordelia]

I've never had a birth where I had a VE before I could start pushing. I didn't have a single VE with my 2nd pregnancy and delivery.

I breathe until I can breathe no longer, even through the urge to push. When breathing the baby down instead of actively pushing you are able to get your baby out without necessitating exams. We knew I was 10cm when baby crowned...lol.

I agree though...sometimes there are reasons to check but to check every single mom when she thinks she's ready to push is overkill, IMO, especially if you're not going to purple push but rather breathe the baby down and out.

I would never birth with someone who said they were never necessary or with someone who said they were always necessary.

[HappyMommy2]

Originally Posted by AnneCordelia

I breathe until I can breathe no longer, even through the urge to push. When breathing the baby down instead of actively pushing you are able to get your baby out without necessitating exams.....

especially if you're not going to purple push but rather breathe the baby down and out.

.

What does this mean?

Did you try to stop your body from pushing? Or did you just not add more push to your body's pushing? Can you please add more words and descriptions to what you are saying? Sorry - I just don't understand what you mean and really want to know!!!

My VERY experienced midwife was surprised that I felt pushy 4 hours after my very first cx. She had checked me 20 minutes prior, and asked me not to push for another 30 minutes. It was horrid. By the end of the 30, I couldn't fight my body anymore and just pushed anyways ... esp at the end of each cx. Baby was born a few minutes later.

This is the only thing that I question about my awesome HBAC, and plan on asking her about it. So I am VERY curious on other people's experiences and opinions.

[phathui5]

Midwifery Today had a good article about this:

http://www.midwiferytoday.com/articles/ruleof10.asp

[tibeca]

My midwife is not so much anti-VE, as she is for watching the woman. According to her, many women experience the sensations of the "next stage" around 30 minutes before reaching that stage. She said watching the woman and really paying attention to her is often all that is usually needed, especially with non-first time mothers.

On the same hand, she doesn't believe in directed (purple) pushing and is often able to see whether someone is really ready to push by watching their demeanor. Unless I ask, or things are progressing well, she won't be doing any VE.

[HeatherB]

With my first HB, I got an urge to push with a lip left, which eventually started to swell. However, it must not have been THAT overpowering because I was able to breathe through ctxs for long enough that the lip went away, and with a contraction or two more, baby was out. (And I was shocked that it was already all over!)

With my second HB, I had a quick VE while in the tub after my water broke. I was assessed to be at 6cm and tight, and advised not to push, which was no problem as I had no urge at all, just super-intense ctxs. Within maybe 5 minutes, though, my body started pushing involuntarily. I was a bit freaked that it couldn't be time yet, but my MW assured me all was fine and to simply not add to it - to breathe through the ctxs and pushing. I was able to get a much better grip on myself and let my uterus push out the baby on its own - which was amazing, BTW! There was never another VE, but my MW knew (as I think all should) that when the uterus is pushing, it's time! She eventually checked and felt the head starting to crown, at which point she encouraged me to feel it (I was glad for that opportunity!). Little one was born 17 minutes after my water broke.

I think following the body's cues while breathing through as much as possible (not adding to pushing) is going to be very effective in general.

[CrunchyChristianMama]

For me, they're necessary. Because of how my babes position themselves in my pelvis and how it's shaped, I start feeling the urge to push at weird times. With my first, a cervical lip that was unable to resolve itself while I pushed led to tons of problems and necessary medical intervention. So with the second I was sure to be checked and cleared to push.

I don't think they are necessary for everyone, but I wish I had been checked with my first and saved myself all the trouble.

[Jane]

Some women want to know, that it's really almost over. I've seen over and over, women that won't push until they know. It's been ingrained in them from previous births that you have to check. Or they have a history of a premature urge and need to know that's not happening again.
If a woman pushes for 20 minutes without *something* changing - her sensations, what I see externallly - then a vaginal exam seems warrented.

[Dov'sMom]

I never had na exam before starting to push because I can't control it -- the urge to push is just too strong. With my first, I didn't even recognize what I was doing as pushing -- the midwife heard that my screaming changed (it was after 50+ hours of horrific back labor and 4 hours of transition -- I had been screaming for hours) and checked me between pushes. With my second, the doctor checked me when I came in at 8 cm and then ran back 30 minutes later to catch DS. With my third, the doctor checked me when I came in at 7 cm. Again at 7 cm four hours later. Gave me a long speech about how we should start interventions now but I was going to need a c-section anyway because my cervix was thickening, yadda yadda. Ran back in 30 minutes later (no interventions) just in time to catch DS and avoid eye contact.

[MsBlack]

Originally Posted by Apricot

Some women want to know, that it's really almost over. I've seen over and over, women that won't push until they know. It's been ingrained in them from previous births that you have to check. Or they have a history of a premature urge and need to know that's not happening again.
If a woman pushes for 20 minutes without *something* changing - her sensations, what I see externallly - then a vaginal exam seems warrented.

Agreed

If I have any doubt, whether from non VE signs or from VE, about whether it's really time to push but mom really wants to, then I step back so she can do what feels right without my interference-- and ask her if she can feel baby moving down, whether or not it hurts to push--well, unless it becomes obvious right away that pushing IS or IS NOT right for that moment.

[jennica]

I can't control pushing either way, so what difference would an exam make? My last labor (2 weeks ago) was 2 hours and 15 minutes total. During transition my body started pushing at the ends of contractions. With my previous labor this happened, but these were just grunty pushes and it felt good. This time it felt bad and wrong and like I must be pushing against cervix. I probably was, and Dd was probably posterior which is why it didn't feel quite right. Anyway, if I had been examined and it was found I was pushing against cervix, what could have been done about it? I didn't really want to push already, but my body just did it. It was such a powerful urge there was no stopping it. It didn't swell my cervix as I moved right into the next phase of labor. After transition during real pushing, it felt good and the baby came right down and out in only 13 minutes. No problems, no swollen cervix. From what I've read, a swollen cervix isn't the result of pushing against it, it's the result of a baby that is positioned in a way that puts pressure on the cervix.

[MegBoz]

Originally Posted by Twinklefae

The thing about that, is that you could have done yourself some serious damage, pushing before you were fully dilated.

Well, I think that is the crux of the issue: "Do you need a VE before pushing (to confirm you're 10cm dilated)?" The question really is:

"Can you damage your body by simply listening to your body's cues without physical evaluation of your cervix to confirm full dilation?"

How likely is it that just following your body's cues will lead to damage?

What I've read about what is referred to as "The rule of 10" as well as common sense tells me Ms. Black is right - in most cases you CAN simply trust your body.
In my case, I'd heard one (2nd hand) horror story about pushing on a non-10 cervix, swelling, & the need for an epidural in someone who otherwise wanted to avoid the epi. I'd NEVER heard the opposite - that sometimes women push on a non-10, but often they're not full-power pushes, & they sometimes HELP complete dilation, AND telling a woman to fight the urge can cause even more problems. So I thought the check was necessary.

Looking back, that check was sooo not necessary! Even though 1st stage was only less than 5 hours for me - quite fast for a 1st-timer - the signs were all there, the sensation was clear. If I have anywhere near that degree of certainty with #2, I definitely will TELL my MW, "I'm feeling the urge to push now." and not ASK her to do a VE to let me push.

Originally Posted by AnneCordelia

I would never birth with someone who said they were never necessary or with someone who said they were always necessary.

ITA

[Twinklefae]

Originally Posted by MegBoz

Well, I think that is the crux of the issue: "Do you need a VE before pushing (to confirm you're 10cm dilated)?" The question really is:

"Can you damage your body by simply listening to your body's cues without physical evaluation of your cervix to confirm full dilation?"

Yes, yes you can.

Originally Posted by MegBoz

How likely is it that just following your body's cues will lead to damage?

With a malpositioned baby? Quite likely.

Originally Posted by MegBoz

In my case, I'd heard one (2nd hand) horror story about pushing on a non-10 cervix, swelling, & the need for an epidural in someone who otherwise wanted to avoid the epi. I'd NEVER heard the opposite - that sometimes women push on a non-10, but often they're not full-power pushes, & they sometimes HELP complete dilation, AND telling a woman to fight the urge can cause even more problems. So I thought the check was necessary.

Add me to your list. I had an epi to UNSWELL my cervix. And thank goodness I did.

And for some of us, yes, they are full on power pushes, and they are unstoppable. And they can do damage without hurting. Pushing felt SO GOOD, even though it was SO WRONG. I cannot drive this point home enough. I don't feel that anyone is listening to my story - it can happen. I would rather have 100 unnecessary VE's than have one c-section because I refused it.

[Jane]

I've seen women spontaneously push a baby down with a cervical lip leading. That's probably damaging to the pelvic floor - the cervix not supposed to be so low as to be seen. It certainly hurts like a mother.
I heard it in her voice, the painful shreik - but it took 20 minutes to convince her to let me check, and reduce the lip. 5 pushes later, a she birthed her baby into her own hands.
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[CrunchyChristianMama]

Originally Posted by Twinklefae

Add me to your list. I had an epi to UNSWELL my cervix. And thank goodness I did.

And for some of us, yes, they are full on power pushes, and they are unstoppable. And they can do damage without hurting. Pushing felt SO GOOD, even though it was SO WRONG. I cannot drive this point home enough. I don't feel that anyone is listening to my story - it can happen. I would rather have 100 unnecessary VE's than have one c-section because I refused it.

Add me as well. This was my story exactly. Pushing felt so, so good, but did damage. I spent over 3 hours trying to get the swelling down, but to no avail. I got an epi and 45 miinutes later the swelling was gone because it got my body to stop pushing against an incompletely dilated cervix.