Do not read this post, if you are not comfortable with the word, "Vagina." This word will be used in this post. If you are not comfortable WITH vaginas, then this post may or may not help you to become more comfortable with them. We'll see. Personally, I am comfortable with vaginas. I have one; and I have seen and examined thousands of them and even repaired a few. I have taught people about them and have talked about them a LOT with their owners. For me, they are like a mouth to a dentist, just an orifice of the body, like any other; and I am not embarrassed by them, except when it comes to mine. I am pretty particular about who I share mine with. We all should be; and we as midwives, should feel privileged when someone chooses to entrust theirs to us.
Lately, there has been a lot of controversy about vaginas, particularly in the examination there of. Many women are beginning to fear them and made to believe that these exams are an unnecessary expression of practitioner dominance over the female victim. Practitioners, who perform these examinations are being persecuted by the "Trust birth-ers" and their midwives, by being called "Birth rapists" simply for believing that there is a time and a place for vaginal information.
Women who have allowed someone to examine their vaginas are being informed of their "Violated" status in society and referred to therapists to heal from the experience. They are now able to join support groups and receive acceptance into elite groups. And to think of how many of us have been victims of dentists who have place their fingers in our mouths! Where is MY "Oral rape" support group? I am WAY more traumatized by my dentist than by my midwife!
OK, so, I believe that I am a "Vagina expert" and am quite qualified to speak on the subject. I will examine (no pun intended) the physiological and psychological aspects of the vaginal exam - Why we do them, why you might want one, what valuable information there is to be found inside a vagina and when they are necessary or not necessary.
When a pregnant woman comes in to my office for her first prenatal exam, one of the first things I tell her is, "Relax, I won't be doing a vaginal exam today," because sheesh! What's the hurry? Why does a pregnant woman need a PAP smear right now? Why perform pelvimetry when there is still so much "pelvis opening" to take place over the next several months? Why feel the size of the uterus from the inside when you can feel it from the outside? Why look for signs of pregnancy when we have advanced detection kits at Walmart?
There are physical "reasons" why doctors (or midwives) perform vaginal exams during the first prenatal exam, but according to an old 1955 Obstetrical textbook that I have on my shelf, there are also psychological reasons, It reads, "The initial pelvic examination also serves to establish an intimate relationship between patient and physician."
(WHAT!?)
Apparently, physicians have known, for years, the fact that when a women disrobes for him/her (usually him, we'll call him "him") she begins to view him differently than she does any other man, except for her husband, of course. The doctor has now earned her trust, simply by seeing her naked. If you are a woman, then you know what I mean. This is called, "Job security," but I am not going to talk about that right now.
Putting aside the psychology involved: In 30 years of practice, I have not yet seen a "safety" need for routinely subjecting clients to the humiliation of pelvic exams during their first prenatal visit, especially when there is plenty of time for that later; but is there ever a good reason for such an examination during the course of the pregnancy? There is; and here are a few examples:
- When the client requests a vaginal or rectal exam due to physical problem/s she is having in those areas.
- When there is vaginal bleeding or cramping - symptoms of miscarriage. A gentle vagina exam could determine if the cervix is dilating, pointing to a threatening miscarriage. Using a speculum and swab can help the practitioner to determine where the bleeding is coming from. ex: from the cervix or a ruptured vessel in the vagina?
- When there are symptoms of threatened premature labor. A gentle vagina exam can determine if the cervix is dilating, effacing, coming forward or is low in the pelvis or if the water is bulging. Contractions that are affecting the cervix might also be detected during the exam and the strength of those contractions noted. I have had cases where such an exam has alerted us to a real threat and enabled us to prevent a premature delivery. In one such case, I found a 5th time mom, who had no symptoms except for her husband had a "feeling," to be 5 cm dilated, 100 % effaced, head engaged and membranes bulging. She was not having contractions, but the threat was REAL. I alerted the pediatrician and hospital and then had her husband carry her to the car and drive her home. She was put on strict bed rest and given a herbal blend to prevent contractions. I made house calls to visit her. She held the baby in for 5 more weeks and delivered only 3 weeks early, at home, after only 20 minutes of labor. That is a success story that began with a vaginal exam. Without the exam, things would have turned out differently.
- In later pregnancy to confirm the position of the baby or assess the condition of the cervix.
Now let's address the late term pregnancy vaginal exam: What are we looking for or hoping to find in those "Dilation checks?" beginning at week 36-37.
- Presentation - do we have a head down (cephalic) presentation or something else? This is very important to know for safety reasons. Although fetal position can be palpated through the abdominal wall, this is not always foolproof. The vaginal exam confirms what we thought we felt or couldn't feel through the abdomen. We can also feel other fetal body parts that might present with the head, or even a cord.
- Cervical station - how low is the baby? In a first time mother, we are not surprised to find the baby engaged in the pelvis two weeks prior to delivery. A multipara might have a "Floating" head that risks a prolapsed cord, should her water break while the head is still floating.
- Effacement - This is even more important than dilation in predicting labor, but most people don't know this. How thin (or short) is the cervical neck? This usually, but not always, is related to how low the head is.
- Cervical consistency - How soft and/or elastic is the cervix? In the last few weeks of pregnancy the tissue of the cervix actually goes through changes in its cellular structure. A practitioner who is very familiar with the "feel" of cervices can detect these changes. When a cervix is not ready for labor, it will not only feel firm, but it will feel like there is a thick, unyielding, rubber band or drawstring inside of it, holding it firmly closed. Just before labor begins, that "rubber band" will release and the cervix will become loose and elastic as if you could easily stretch it in any direction. When I feel this, I know I need to get to bed early that night. If the cervix is very thin, elastic and low, I know I need to instruct the mother to call me with the first contraction and that when she does, I need to hurry, even if the cervix is not very dilated at the time of the exam. This knowledge can help prevent the birth from happening in the car, on the way to the hospital or birth center or unattended at home with a screaming father on the phone and a midwife sitting on the side of the road receiving her speeding ticket. (yes, this has happened)
- Angle and position of the cervix - is the cervix easy to find in the front of the vagina, or is it way behind the baby's head? Is it off to one side or the other? This is a really good clue as to fetal head position. A posterior cervix is common with a posterior baby. With an acynclitic baby the cervix is likely to be to one side or the other. Mother can then use techniques for helping her baby nestle into the pelvis to facilitate an easier delivery. (but NOT the "spinning babies" technique Please! THAT is another blog subject)
Vaginal exams during the last few weeks of pregnancy are performed more to satisfy curiosity than for safety purposes, although it can be quite helpful psychologically for the mother to know how she is progressing toward labor and what she can expect once it happens. There are natural remedies for tough cervices that can help to prevent a long or overdue labor if this condition is learned of soon enough in advance.
Mothers love to be involved with their pregnancies and know what is going on. I even recommend that they learn to examine themselves so they can get to know their cervices. This helps them during labor to focus on where the pain is coming from and what benefit it has for them. If she knows that the pain is opening her cervix, she will welcome it more. A mother might also like to know when to have her mother come to town or when her husband needs to stop leaving town. These are all benefits of a good prenatal "cervical reading," but not always safety necessities.
Now I will address vaginal exams during labor: This type of exam has come under brutal attack lately, but I have not heard a legitimate reason WHY. Women are just being told that it is wrong and that they need to say "No." Practitioners, particularly midwives, are being persecuted if they do them, even when it is at the mother's consent or request. If you want to get everyone's attention at a midwife herbal tea party, just tell someone that you do vaginal exams; and the room will suddenly become quiet and look your way. Not yet, has one of these vagina-phobic midwives given me a good reason WHY vagina exams are wrong, SO how about I give YOU and THEM a good reason WHY I do them and why I recommend them, at least once during each labor?
I have had cases where a vaginal exam, during labor, has been life saving. Yes, literally saved the baby's life. Is THAT a good enough reason? I have had more cases where a vaginal exam during labor has prevented a c-section or hospital transport or other unwanted interventions. I have known of cases where NO vaginal exam has led to a disastrous outcome. How about those for reasons?
In one such case of disaster prevention, labor was progressing quickly. When I arrived and saw her laboring, I figured I hardly had time to set up before the baby would emerge. There was no reason to suspect any kind of problem. It was her 3rd baby and the last one had nearly fallen out without much effort. She was laboring hard on all fours and I sure didn't want to intrude, but thinking of unknown possibilities, I suggested a quick "Safety check" vaginal exam, to which mother agreed. To my surprise, my fingers touched an eyeball and eyebrow with an ear off to one side. The baby was locked down hard in this position being shoved in harder with each powerful contraction. I had just examined this mother earlier that day and found a perfect presentation. It's a good thing I didn't assume everything had stayed the same! I transported her immediately to the hospital. The receiving OB wanted to wait and see if the baby could be born vaginally, face first, but as soon as the mother's body began to push, she pulled back and yelled, "It's hurting him! I need a c-section!" So the doctor agreed to perform one. As they were prepping her for a c-section, the baby suddenly crashed, meaning his heartbeat began to drop rapidly with no recovery or variability. He was dying suddenly and quickly. The baby was barely saved by an emergency c-section. Luckily the only bad outcome was a baby with a very swollen, black eye and brow.
In another case of disastrous outcome: (This story was told to me by the midwife herself and then again later by the father of the baby) The mother labored for several hours and, just like in the last story, it seemed that everything was going along normally. The midwife decided to get some sleep but after it seemed that too much time had gone by without being called in for the birth, she decided to do a vaginal exam to see what the hold up was. She found the baby's arm in front of the head, sticking its elbow into the vagina. The mother was 8 cm. She transported the mother to the hospital but it was too late. The baby had been allowed to descended deep into the vagina elbow first! A c-section was performed at the hospital but the baby sustained irreversible brain damage.
In another case, (twins) the initial exam found a normal head down position, but during another exam, an hour or so later, it was found that an umbilical cord had slipped down beside the head. The membranes were still intact and the babies were not in trouble....YET, but because this potential for disaster was detected, a disaster was prevented.
I have too many more stories to tell to illustrate the importance of vagina exams during labor, for safety reasons. The fact is, no one can know, for sure, what is going on in there, without examining it. Yes, I have heard that you can feel the dilation of the cervix by palpating a mother's foot (heal) or one can tell by other "energy" tests if all is well in there. I love to ask the people who do this sort of thing to tell me a woman's dilation BEFORE I examine her. I've not yet seen one instance where dilation was correctly estimated by palpating a woman's heal, but if no one is doing a vaginal exam to confirm it, they can say whatever they want. I am still open-minded and waiting to be convinced.
What about other benefits of vaginal exams during labor? Are there any?
YES.
-Through a vaginal exam, a midwife can meter the intensity of the contractions in relation to progress that is being made. She can learn how different labor positions or techniques are aiding in the progress of labor. She can identify fetal position and rotation to learn if a certain position is helping the baby to rotate and come down better than another. This can be quite beneficial to a mother who may not want to be in labor longer than she has to. She can also detect cervical abnormalities that may hinder progress, like scar tissue from past medical procedures that can't be identified until labor has had a chance to open it.
-Through a vaginal exam a midwife can help a mother to focus on her cervix, to relax it and allow it to open. This is quite helpful to women who are panicking from the pain of labor. I ask them if I can try something to help them focus and explain what I will be doing. With their permission, (I have to emphasize that because I know someone is going to copy and paste this onto their blog) I simply place a finger on either side of the cervical opening, within the vagina, touching it lightly. With the next contraction, I tell them to focus on where I am touching, to relax it and allow it to open while they mentally "drop" their baby through the opening. In most cases, the mother will ask me to do that with each consecutive contraction until full dilation, because it helped her so much. I have even had them scream at me, "GET YOUR FINGERS IN THERE!"
An added benefit of this technique is the unique understanding of labor that is gained by the midwife who is privileged to feel it happening under her touch. Labor progress is much more than simple dilation and cervices don't just merely "open." They change in other ways too. Did you know that the cervix is actually SUPPOSED to swell just before it slips over the babies head in full dilation? Too often, this swelling is blamed on premature pushing because mothers are simultaneously feeling urges to push at the same time. So, how do those "rule of 10" professionals explain the cervix that swells even though the baby's head is not even applied to it because it hasn't descended yet? With few exceptions, the cervix will swell slightly, then it will pull into a shape that resembles the beading around the neck of a balloon, next it becomes paper thin; and then the head slips through it. This can all happen in one contraction for some lucky ladies but for first time mothers, it can take awhile.
Through a vaginal exam a good midwife can detect CPD (cephalo-pelvic-disproportion). Although this condition is far too often misdiagnosed in hospitals, it can actually happen. In these cases, the baby's head is molding while it is still high in the pelvis because it is TRYING to get in. In other words, it acts as if it is lower in the pelvis when it is not there yet. In a normal female pelvis, the entrance of the pelvis is wider than the outlet, like a funnel, becoming progressively tighter. The baby's head will normally mold (bones overlap) as it descends, not before it descends.
As I write, SO many personal experiences come to mind of vaginal exams that have provided valuable information, not only for safety in birth, but for ease of birth.
With so many benefits to vaginal examination, I ask again, WHY would someone refuse to provide this service or advocate against it? Well, I have asked them myself and these are the only responses I have gotten:
Reason #1 - "A pregnant or laboring mother should be thinking "Down and out." When we place fingers "Up and in." it confuses her."
(My answer) "hmmm, Didn't something go "up and in" to get her pregnant in the first place? Isn't this (sex) also happening throughout her pregnancy as well?"
Reason #2 - "Risk of infection."
(My answer) As long as the Amnionic sack is intact, there is no more risk of infection than having sex or taking a bath during pregnancy.
Reason #3 - Most of the time that I ask this question, I just get a, "Because it's wrong. It's birth rape!" answer.
(My answer/question) When did we, as a society, start believing that everyone who touches us is doing it with evil intentions or sexual motivation? I wonder why chiropractors, dentists, massage therapist, hair dressers and ear, nose and throat doctors aren't being socially attacked for the same reasons? After all, aren't they touching us too, maybe even in one of our orifices?
Could it be that vaginal exams went "out" with midwife apprenticeships and the introduction of classroom training, lacking adequate hands on training? Could it be that midwives no longer are being taught HOW to do them and therefore they fear them or simply don't have a clue what they are feeling when they get in there?
I had one such midwife, who had nearly been on as many births as I, call me out to a stalled birth, simply because she needed someone who knew how to "Read" a cervix to figure out what the problem was. I did figure out the problem right away and got her to the hospital, just in time to save the baby's life, via c-section. The cervix was damaged and unable to open; and in the 3 DAYS of hard labor, the uterus had become filled with deadly infection.
I had an apprentice once, who moved away after attending only 7 births with me. There was no apprentice training available where she moved so she attended and graduated from an expensive midwife college instead. After receiving her degree, she practiced for about 5 years before calling me and asking if she could spend a summer with me to get some more "Hands on" training, to which I agreed. During that summer, I was really surprised at how awkward she was with her hands on skills. She had trouble palpating babies, finding their heartbeats and had no clue what she was feeling during vaginal exams, yet she was a practicing midwife!
It probably took me at least 50 vaginal exams before I BEGAN to recognize what I was feeling. Women, who are in their last trimester of pregnancy, have so much vascularity and so many folds in their vaginas that it can feel like nothing but mush in there to a novice. It can be discouraging, embarrassing and scary. I am sure it is much easier to tell your clients that you are being kind by not subjecting them to such an "invasion" rather than to admit that you don't know how to examine them.
Oh, they will tell you that they DO know how, but if they don't do vaginal exams, then I guarantee that they DON'T know how. This is one skill that is learned and refined by DOING it...a LOT. I often tell clients that I have grown eyeballs on the ends of my fingers.
Over the years and spending many cumulative hours with my fingers in vaginas during all stages of labor, has taught me to "see" the cervix in my mind without my fingers in there so much anymore. No one can gain that keen understanding without first getting to know the cervix by physical touch.
All in all, each vagina belongs to it's owner, not the doctor, the nurse or the midwife.
Vagina exams, (Yes? or No?) are ultimately HER choice.
Elizabeth Smith
Licensed, Certified Professional Midwife
435-632-8998
