Inital physical exam?

[Reha]

I am wondering how many of you midwives actually do an initial physical exam with clients? It certainly isn't the standard of care in these parts, but I know that NARM seems to be pressing this issue, and wants this done (for those doing the PEP process).

If you have received midwifery care, I would be curious to hear if your midwife did an initial physical exam, and how you felt about it.

Thanks!

[Jane]

All of my preceptors do one. Most everyone for all clients, but one midwife didn't do it if the client transferred care from a doc and it was in the paperwork.

[BetsyS]

I saw a CNM, and she did an initial PE.

[sevenkids]

We do. For most of my clients, pregnancy is the only time they have insurance and access to a HCP and may not have had a physical in 2, 3, 4, or 5 years or never, some have never had a pap or breast exam.
The initial visit is typically spent talking and doing a routine visit, the second or third visit we do the complete exam and that visit takes about an hour and a half.
If they came from a doctor and had a complete physical and the records are forwarded, I don't do one.

[rnchrista]

Originally Posted by Lennon

I am wondering how many of you midwives actually do an initial physical exam with clients? It certainly isn't the standard of care in these parts, but I know that NARM seems to be pressing this issue, and wants this done (for those doing the PEP process).

If you have received midwifery care, I would be curious to hear if your midwife did an initial physical exam, and how you felt about it.

Thanks!

We are trying to get in the habit of doing them, mostly to prepare ourselves for the NARM.

[cfiddlinmama]

You know, Lennon, I've been thinking about this alot. I've been studying pelvimetry, and I can honestly say with 4 pgs I've never had it done. I've had 1 CPM and 3 CNMs. I've had hospital pelvic workups for preterm labor (STD checks, etc.) Is it possible that a mw could do all the measurements so quickly I would think it was part of a VE? I'm going to have to talk to my preceptor to be about this... (She was my CPM) Or is it even necessary to measure the pelvis?

[JunipersMom]

I dont do them, and none of my preceptors did them. I did study how to do them for the NARM, but really never thought about it until this post. I guess I still wouldnt feel too comfortable doing a physical without a bit more understanding of what to look for. If a mom has a question about something, we explore it and I do self breast exam information for my moms ~ but other than that nope.

[CarolynnMarilynn]

I do one to screen for a heart murmur, abnormal thyroid, to discuss varicose veins, and to offer a breast exam, among other things. I check reflexes to establish a baseline in case of high blood pressure later on. I offer a pap and swabs and complete blood work. A good percentage of my clients do not have access to health care, and many do not see a physician for regular check-ups. I have found abnormal moles, found breastlumps, found undiagnosed heart murmurs, etc. I think it is valuable.

Also, I think that a normal physical assessment confirms that the woman is in the scope of midwifery care as a well woman. I do the exam on my second visit after the initial health history.

[Reha]

This is all very interesting. thanks for all who've shared so far!

[Carolinamidwife]

I definitely will. Part of the reason I decided to add an extra 4 years to my education (sort of lol) is because my interest had expanded from maternity care to well-woman as well. When I apprenticed as a CPM candidate only 2 preceptors of the dozen or so I worked with did full exam and one of them was a CNM and the other was a CPM trained by a CNM. Had I continued the route to CPM I'm not sure if I would have done full exams, I never felt fully confident in my abilities above the waist.

[Reha]

I guess that personally, I would be put off if my midwife wanted to do a pe. Though, I have thought about it maybe being something that is offered if the woman would like it done. Personally, I would refuse it, but I know some women might feel better to have it done.

[Defenestrator]

I like the idea of doing it on a second or third visit if it is going to be done. It just seems like a lot to put into the first visit and also I think it sets the wrong tone -- it seems to say that your care is going to be medical and possibly physically invasive. I don't do them currently -- I consider them to be a little bit outside of my scope of practice and also there are practical considerations as well. I do all my visits as home visits and there are often kids scampering about. It is hard to do any kind of hands-on examinations that last more than a minute or two and sometimes awkward to have women undress. I do paps postpartum if women are due.

Could it be broken up into several visits? I think I might find it easier to do in that case.

[DisplacedYooper]

Not a midwife, but I had no physical exams at all (pre-natal that is) until everyone was wondering why I had been pushing for 2 hours and hadn't had a baby yet (cervical lip)

I would have been uncomfortable with the idea of needing a vaginal exam for midwifery care - I trust that my body is what it needs to be to have babies! (on that note, I see a nurse practitioner on campus for paps, etc)

[the_lissa]

Originally Posted by Lennon

I guess that personally, I would be put off if my midwife wanted to do a pe. Though, I have thought about it maybe being something that is offered if the woman would like it done. Personally, I would refuse it, but I know some women might feel better to have it done.

Yes. My midwives offer it if the client wants it or it has been a while or whatnot.

I wouldn't do one.

[CarolynnMarilynn]

Originally Posted by the_lissa

Yes. My midwives offer it if the client wants it or it has been a while or whatnot.

I wouldn't do one.

I didn't have one either because I had just had one with my family doctor. I offer them to all my clients. They can say yes or no, no problem.

[CarolynnMarilynn]

Originally Posted by Lennon

I guess that personally, I would be put off if my midwife wanted to do a pe. Though, I have thought about it maybe being something that is offered if the woman would like it done. Personally, I would refuse it, but I know some women might feel better to have it done.

I am curious why you would be put off if she offered to do a physical assessment?

[Reha]

It just comes off as too medical minded for me, I guess. I think I would be fine if it were presented as an option, and it was no big deal if I declined. But, it really seems like so many things like these are presented as the standard, and women assume that there must be a good reason for us even wanting to do them, so they just go ahead with it.

[pamamidwife]

I agree with Lennon.

As a student, I learned the basics of physical examination. I definitely know how to listen to lungs, check out varicosities, skin issues, the heart and the ears. Basically, that is all I've ever been asked to do - and most of it's been on children (not babies) of clients (ear infections, deep cough, etc). If something came up, I could always refer to my texts or call a friendly physician.

I'm fortunate to live in an area that is urban and has accessibility to health care providers. If I did find something on a PE, I'd likely have to refer to a general practitioner anyway - I'm not an expert in overall health. It's not my focus of practice. I do, however, have a general understanding of what is normal and what is not to help collaborate with clients.

I don't do paps in pregnancy because of the high false interpretations. I find women with breast issues that are nice to know ahead of time (and true inverted nipples is just about the only thing I can think of that would be beneficial to discuss prenatally) have a tendency to ask about it themselves.

I'm glad that it's part of the education process, but I also know that unless I was the only health care provider in a rural area, I'd definitely refer to a provider that not only does more than I could ever do, but has the ability and resources to follow up any abnormalities.

re: pelvimetry - it's nice to know the basics for the NARM, but it's so antiquated and not accurate in terms of who could deliver vaginally that I would never use it. I think Anne Frye has some good info on this.

[BetsyS]

Originally Posted by sevenkids

We do. For most of my clients, pregnancy is the only time they have insurance and access to a HCP and may not have had a physical in 2, 3, 4, or 5 years or never, some have never had a pap or breast exam.
The initial visit is typically spent talking and doing a routine visit, the second or third visit we do the complete exam and that visit takes about an hour and a half.
If they came from a doctor and had a complete physical and the records are forwarded, I don't do one.

In my experiences when I was working, this was my patient population. We did exams to pick up on things because, other than pregnancy, our population used the ER as primary care.

I guess, to me and my colleagues, it felt like part of caring for the whole woman, and not just her pregnancy.

[Charmie981]

A lot of what is observed in a physical exam can be broken up and/or checked non-invasively. I NEVER do a pelvic until labor unless mom asks me to check her prenatally and often I tell her I prefer not to and WHY I prefer not to. I just write "deferred" in those boxes on my forms.

I also have the issue of doing mostly home visits and having clients who want me to simply be there for to care for her during pregnancy. I don't know enough to really know if something is wrong with what I'm seeing/finding and feel like it's outside of my scope of practice, for the most part.

I have, however, decided to do a breast exam on first time moms at some point during their pregnancy. I've had two moms disrobe in labor and noted, for the first time ever, that they had severely inverted or flat nipples. From experience as a woman, I know that many of us with inverted nipples don't know they're inverted and that it would be really beneficial to know BEFORE you're in labor!! Since they're first time moms and don't have kids running around, it will be much easier to facilitate a breast exam, too .