vaginal exams during labor

[Dov'sMom]

Are they really necessary?

I'm birthing with a practice of ob/gyns, and I asked in my birth plan to avoid vaginal exams besides the one when I arrive and if/when there seems to be a qualitative change in my labor. The doctor I was talking to, who is generally fine with being hands-off (she skipped the routine vag-check at 36 weeks and seemed fine with not doing any until 40 weeks) insists that it is necessary to check every so often to see how/if I'm progressing.

I don't see why, exactly. If the baby is doing well, and we don't plan to allow any medical interventions to speed up labor anyway, what's the point? She says she doesn't do an exam every hour, just every few hours she feels like she needs to see what's happening. Of course, I would hope not to get to the hospital too many hours before birth...but still.

[gratefulmama2isaac]

No, they are not necessary. You might ask her to give you a concrete explanation for why she considers them to be necessary. Then do your own research on the answer she gives you. If she says she needs to see how you're progressing; why? Is she going to impose a time limit on your labor, particularly if you membranes are ruptured? These are really good things to know, but getting concrete answers can be hard.
A skilled care provider can recognize signs that a labor is progressing w/out a vag exam, i.e: contractions increase in intensity and duration, becoming longer, stronger and closer together. But if this provider never sees normal birth, she may be used to only assesing through vag exams.
Also, doing an exam anytime before labor starts tells you nothing about when labor will or will not start. A mom may walk around 2 cm or more for weeks before she goes into labor, or leave after being told she has a rigid, closed cervix and go into labor that night.

[SublimeBirthGirl]

Amazingly and to everyone's shock and awe, my 2nd child was born even though I never had a vaginal exam. Gasp! Not only are they unnecessary, they can be harmful in many ways.

[skyblufig]

Originally Posted by SublimeBirthGirl

Amazingly and to everyone's shock and awe, my 2nd child was born even though I never had a vaginal exam. Gasp! Not only are they unnecessary, they can be harmful in many ways.

up Mine too! It's a miracle they're able to find the exit without someone shining a light in there. In fact, it surely must be a miracle she's not still in my uterus, 14 months after being conceived.

OK, sorry for the sarcasm, it's just the mw I saw at the beginning of my pg tried to say the same thing.

I ended up firing them.

[hippiemom]

I ama doula and childbirth educator, and have 3 kids of my own... just to tell ya where I'm coming from.

Anyway, no, they are not medically necessary unless some unusual problem is suspected. Other than that they should be optional and done only with consent of the birthing couple who want information at the time. And even then, keep in mind that if you are at 4cm one hour, you can still be at 4cm 3 hours later, or you can be at 10 an hour later, etc... yes the important part is how mom and baby are tolerating the labor. You will know when it is time to push without anyone looking inside you. The midwives and I used to chuckle and say we couuld tell by the mom's FACE that it was pushing time!

[mwherbs]

how else is a doctor to "phone manage" a birth? the nurses give reports to other nurses and they report to the doc- the docs are either in doing other surgery and stop by and get a report or they are not at the hospital and are out and have "standing orders" for different potential situations -- having someone check dilation is a portion of the info that makes up the decision tree--- along with timing and strength of the contractions , heart tones, your BP and temp, how long you have been in the hospital...

[nashvillemidwife]

Originally Posted by hippiemom

keep in mind that if you are at 4cm one hour, you can still be at 4cm 3 hours later, or you can be at 10 an hour later, etc... yes the important part is how mom and baby are tolerating the labor.

But keep in mind that mom and baby won't tolerate labor forever. You've got to temper the length of labor with the progress of labor. The important thing is that progress is being made. It doesn't have to be made rapidly, sometimes it's in descent, effacement, and/or position of the cervix. If hours have gone by with no change at all, that's not normal, and there's a reason why it's being held up.

I don't do many vaginal exams, but I think slow progress is a valid indication to check what's going on.

[SublimeBirthGirl]

Originally Posted by nashvillemidwife

But keep in mind that mom and baby won't tolerate labor forever. You've got to temper the length of labor with the progress of labor. The important thing is that progress is being made. It doesn't have to be made rapidly, sometimes it's in descent, effacement, and/or position of the cervix. If hours have gone by with no change at all, that's not normal, and there's a reason why it's being held up.

I don't do many vaginal exams, but I think slow progress is a valid indication to check what's going on.

I totally disagree. There is no way of knowing what length of labor any given mother and her baby can tolerate. There is no way, from knowing a woman's dilation, to know if she is making progress, because there is so much more to labor than dilation. I went from 4 to 10 in an hour after not dilating during literally an all-night labor (she was born at 9:27 am). Thinking that this information tells you anything of value is one of the problems with exams. Leave mom alone. If she and the baby are fine, let things unfold.

[doctorjen]

As long as mom and baby are fine, mom isn't wanting to know dilation or asking for pain meds, and there is no special concerns (like the rare instance of known cervical scar tissue, or something, where I could maybe see wanting to check for progress a few hours down the road if nothing seemed to be changing) I don't really do exams. I don't even do exams if moms want to push - eventually they start pushing, and generally a baby comes. And I practice in a hospital!
The issue mwherbs brings up is probably the major reason docs want cervical exams. If you are not planning to be in the hospital, you have to have some kind of plan for when you are going to come to the hospital. As a family doc, and not an OB, I attend few enough clients that one of the things I provide routinely is my presence during labor. So if I'm standing there anyway, and we aren't going to make a plan change, I don't do exams. I have one client for whom I've caught 2 babies whom I've never done a single exam.
For many of my clients, though, they ask for exams because they want to know where they are, or, they want pain medicine and so have an exam to make sure they aren't too close to birth (not that we can predict that for sure as several of you point out!)
I've had the experience of doing an exam, finding an 8 cm cervix, and having the baby follow my hand right out of the mama - much to my shock, and the mother's, who I'd just told she was still only 8cm! I've had people be 3 cms, and holding their baby in 25 minutes, and I've had people be fully dilated and labor several more hours before an urge to push - so cervical exams are definitely not 100%.

[nashvillemidwife]

Originally Posted by SublimeBirthGirl

here is so much more to labor than dilation

So I said.

But how long do you sit by and tell a woman her body is doing its work when its actually not? And how do you know? How long does she have to push before she finds out her efforts aren't doing anything?

There are certain circumstances in which I recommend vaginal exams: if the mother requests, if we are not sure if the mother is really in labor, if several hours of active labor go by with no change in contraction pattern (duration, frequency, intensity), prolonged pushing (varies, but generally 2 hours with first babies, 1 hour with multips). If there is any change at all in any variables (dilation, effacement, position, descent), her labor is just long. If there's been no change at all, her labor is not progressing normally and we need to start considering why.

Let's not forget that sometimes dysfunctional labor really does happen; might be because the baby's tangled up in his cord and if so could be a perilous delivery, or breech and requires transport, or true CPD and no amount of pushing is going to get him out, or deep transverse arrest and he is stuck. Or it could simply be a large baby, or a malpositioned baby that just needs extra time to figure his way out. How are you going to know? I don't see prolonged labor or pushing very often, but when I do I know there's a reason, and I want to know if it's a reason that warrants transport. If anything is changing I know the baby is coming, slowly but surely. If over several hours there is no change at all, something is wrong. And I do generally wait several hours before reassessment.

I'm not advocating for routine vaginal exams as I don't do them myself, but I wanted to point out that there are valid indications.

[nashvillemidwife]

I guess I never mentioned that I'm coming from the homebirth perspective. My reasoning doesn't necessarily apply to hospital deliveries.

[mwherbs]

nashvillemidwife I agree with what you have said here- an exam is information- and sometimes we want to access it --

[maxmama]

Originally Posted by nashvillemidwife

But keep in mind that mom and baby won't tolerate labor forever. You've got to temper the length of labor with the progress of labor. The important thing is that progress is being made. It doesn't have to be made rapidly, sometimes it's in descent, effacement, and/or position of the cervix. If hours have gone by with no change at all, that's not normal, and there's a reason why it's being held up.

I don't do many vaginal exams, but I think slow progress is a valid indication to check what's going on.

Yep.

I labor-trained on a unit that did exams every two hours. It was VERY hard to change to my current unit, where we check moms pretty much if they want meds, if they seem not to be progressing (as in, their labor is not getting more intense), and if they're pushy (primips especially seem to get pushy with descent, even if there's still a lot of cervix left).

Friedman's curve is crap, but there does have to be progress at some point. If something's not working, then why not? Is it position, is it the baby, is it something else?

[SublimeBirthGirl]

Originally Posted by nashvillemidwife

So I said.

But how long do you sit by and tell a woman her body is doing its work when its actually not? And how do you know? How long does she have to push before she finds out her efforts aren't doing anything?

There are certain circumstances in which I recommend vaginal exams: if the mother requests, if we are not sure if the mother is really in labor, if several hours of active labor go by with no change in contraction pattern (duration, frequency, intensity), prolonged pushing (varies, but generally 2 hours with first babies, 1 hour with multips). If there is any change at all in any variables (dilation, effacement, position, descent), her labor is just long. If there's been no change at all, her labor is not progressing normally and we need to start considering why.

Let's not forget that sometimes dysfunctional labor really does happen; might be because the baby's tangled up in his cord and if so could be a perilous delivery, or breech and requires transport, or true CPD and no amount of pushing is going to get him out, or deep transverse arrest and he is stuck. Or it could simply be a large baby, or a malpositioned baby that just needs extra time to figure his way out. How are you going to know? I don't see prolonged labor or pushing very often, but when I do I know there's a reason, and I want to know if it's a reason that warrants transport. If anything is changing I know the baby is coming, slowly but surely. If over several hours there is no change at all, something is wrong. And I do generally wait several hours before reassessment.

I'm not advocating for routine vaginal exams as I don't do them myself, but I wanted to point out that there are valid indications.

How do I know her body is working, or how do you know it's not? If mom and baby are tolerating things, baby's fine, mom maybe tired but coping, dilation etc not changing for several hours, what do you suggest doing? It's one thing if mom's had enough, or baby's having problems-clearly you step in then. But everyone's okay and you want to interfere just for length of labor? Why? And how do you determine when enough is enough when mom and baby are still doing perfectly fine?

Some women have days of active labor. It sounds miserable, but they chose to continue and they and their babies were fine. Would you have interfered because of a clock? What about my friend who had 42 hours of contractions 3 minutes apart and intense, who had no dilation for a very long time? She sprinted at the end and he was born within an hour of getting to the hospital (she'd gone in earlier, thinking she was close, only to go home because of so little progress).

I'm just wondering how you determine when to interfere, if the mom and baby aren't showing signs of distress. And why it is that you get to make that determination. Again, I totally get it if there are signs of distress, but if not-I don't get it at all.

[nashvillemidwife]

I think it's largely an intuitive thing. I believe intuition is your subconscious mind's ability to piece together existing clues that your conscious mind isn't connecting, and I trust it. I don't have time limits, and I work off the mom's cues.

Are you an HCP? I feel like you're saying the midwife should just sit back and wait for fetal intolerance to happen before considering there might be a problem.

[SublimeBirthGirl]

Why does the midwife's intuition outweigh the mother's?

[maxmama]

Originally Posted by SublimeBirthGirl

Why does the midwife's intuition outweigh the mother's?

Midwives have a wealth of experience. While the mom's intuition is important, this may be her first birth experience, or she may be convincing herself she's progressing when she isn't. Why have a midwife if their opinion and experience aren't worth anything?

[SublimeBirthGirl]

I wouldn't have a midwife who put a time limit on me, even though there were no signs of trouble, baby's doing fine, and I feel like everything is fine. Actually, not having other people's anxieties projected onto me during labor was a big part of why I had a UC with my 2nd. I got all kinds of interference with my 1st because of my midwife's nerves (long labor with PROM-though not excessively long, not even 28 hours of ROM-baby fine the whole time and born with 9/10 Apgars). I believe that if she feels confident and unafraid, a mother is the best fetal monitor.

And I'm not a midwife. These types of things are a big part of why I'm so conflicted about my ability to go that route.

[maxmama]

Originally Posted by SublimeBirthGirl

I believe that if she feels confident and unafraid, a mother is the best fetal monitor.

Fear is a tool. Fear alerts us to potentially risky situations. Caution is not a bad thing.

Doing an exam doesn't mean a time limit is being put on anyone. It can be a gauge of where someone is. I've had moms who were asking for an epidural (or a c/s) who are checked, are 9 and feel completely refreshed by that knowledge. Their intuition was not right in this case.

Intuition is one tool. It's not the end-all be-all of birthing.

[mwherbs]

waiting until a baby is in distress is too late, there are a few things like position change that can change things but there is a limit at a point it isn't going to matter-- I guess the thing I see the most is especially first time moms- thinking that they are further in labor than they are, using up their resources, wanting labor to stay the way it is or to slow down because of fear-- and sure if a mom doesn't want to get an exam we can roll with it- but it is higher percent that she will end up transferring -- out of her own wishes-- now I may know better but will only advise to a point will not have a disagreement with a mom-- and the thing is on entering a hospital they will be doing an exam-- and you may say ask to do one but a worn out mom who transfers rarely refuses- I have only seen it one time that a mom carried out refusals of every thing that they talked about refusing-
I think that fear is probably something that effects these ideas- and it is a cultural standard at this point- induction all time highs, epidurals at 90% moms with prodromal labor -going in to be induced- admitted regularly at under 3 cm--- sifting out what is intuition from the baseline fear is not an easy task for the majority of birthing women --