Sunday, January 18, 2009

Undress From the Waist Down

I was asked in the comments how often I do a VE (Vaginal Exam) and since I have a lot of thoughts about this topic, I thought I would just make a post.

I don't like to do VEs. Women don't like to have them done. How often do I do them? When there seems to be a clinical need for one, or we need the information to make a care decision. I also will do them reluctantly if begged by the woman, after I've tried to talk her out of it.

Prenatal vaginal exams are largely useless when done routinely. They are uncomfortable and give misleading information. Moms can be 4 cm and still walk around for 10 days like that. Or they can have a long, closed cervix and have their baby 7 hours later. I have actually heard of women whose doctors told them if they hadn't made "progress" in dilation from one prenatal visit to the next that they would need a cesarean!

The amount of dilation also is not related in any way I've ever seen with how long labor lasts. Faerylady was 5 cm for two weeks before her fifth child was born and she labored for 15 hours to get to 10 cm. I was only 3 cm. 30 minutes before my third child was born.

Many doctors and some midwives will do VEs at the end of pregnancy so they can "rough the cervix up" or "get things going", often without consent or even the woman's knowledge. The mom just knows that the VE is very painful, and she has lots of contractions and maybe some bloody show when she leaves the office. But many times labor doesn't commence. This can lead to trips to the hospital when the mom thinks she's going to have her baby.

I think this is a bad idea for a few reasons, the biggest of which is that the mucus plug has bactericidal properties and protects mother and baby to some degree against infection. Doing a VE, especially a rough stretch and sweep VE, disturbs and removes much of this protective plug. Stripping the membranes is contraindicated in women with Group B Strep. Some women decline testing, and we dont' know their GBS status.

What are some reasons I would do an exam prenatally? I would do a VE if I couldn't tell what the presenting part is. I would do a very gentle VE if I had a mom having a lot of preterm contractions. I would do a long, slow stretch (usually takes about 20 minutes) if I had a mom that was very overdue and we knew she was GBS negative. And I would do one at the mother's request, but with informed consent about the limitations of the information.

Like any intervention/test/procedure, the question needs to be asked "What are you going to do with the information." If it won't affect the care of mother or baby, and there is no change that can/should be made, and if the information can be misleading, why do it?

As far as labor: I still rarely do them. On first timers, I do like to do a VE on arrival at their house. VBACs also. For the primes, it is because they can look like they are in the throes of transition, and be a tight, posterior 1 cm. For VBACs it is because I don't play with obstructed labor and a scarred uterus. If a VBAC isn't making good dilation progress in the face of strong regular contractions, we transport. I still only check every few hours though.

There are lots of moms I have served who I have never checked at all. Many women I can tell where they are in labor with external means -- emotional signposts, the "red line thermometer" between their butt cheeks, the tone of their voices, the quality and intensity of the contractions. Often during pushing, I will tell the moms to reach in and tell me where their baby is and if they are making progress or not. If they are unsure, I will offer to check. As long as they note progress and the heart tones are good, I keep my hands to myself. If we had low heart tones, I get more aggressive with coaching pushing of course.

When else would I check in labor? Again at maternal request. Or if she seems to be complete, but is getting discouraged and/or wanting to push but afraid to. I check any time I hear a problem with heart tones to determine if birth is imminent. And I check if it's been several hours with no discernable external signs of progress.

I always, always ask. The mom can always say no. And I've had so many women remark with suprise, "That didn't even hurt!" It's not supposed to.


Kim said...

Wow! I had minimal VEs with my labour - one (actually two) when my midwives arrived. I was a primip and had been labouring alone for a few hours, so I wanted to know how far along I was so I could know whether to get into the tub. I had a student midwife, so she checked me first and wasn't sure she'd checked correctly, so my primary midwife checked too - 6 cm! I was also checked about 5 hours later when I was feeling a bit pushy, just to make sure I was complete - 9.5 cm! My water broke after that and I had some involuntary pushing, so I think that was the last one. I maintain that the VEs were more uncomfortable than my worst transition contraction.

I also found the post-birth exam to check for tears to be more painful than contrax as well :(

One Hot Mama said...

The post-birth exam to check tears is very painful for most women. I use a numbing gel before checking and this really helps that pain for most women.

Mrs. Spit said...

I had a resident do one while having Gabe. It was the most horrendous thing I've ever experienced.

My midwife didn't do any. When I told her I needed to push, she got me to push. When they asked how dialated I was, she looked at them ,and said "she was ready to push".

Lizzie said...

I'm so grateful you don't do VEs. :)

Amanda said...

Wow... a 20 minute "slow stretch" I wish my midwife had done that. I don't think anything hurts like that. Although even her quick sweep started my 2nd labor that only lasted about 4 hours.

Emily said...

I loved only being checked ONCE my entire pregnancy and birth! And I felt that was very helpful b/c it gave us good info and helped you know how to guide us better--totally worked! :) I'm so happy to have found a MW here who shares the same philosophy. Ahhh....

mommasara said...

i wish i could have you as a midwife!

mamasmotives said...

So I had no idea about the red line or even using it as a guide to dilation. I was like "wth is that?" and googled it, lol.