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Like all prenatal interventions that havebecome routine,
internal exams are quiteuseful in selective situations.
A couple of indications for an internal exam
(also called a vaginal or digital exam) mightinclude confirming
a suspected breech birthwith the intent of turning the baby, or
de-termining the position of the babys head ifthere is a question
of orientation that needsto be corrected before labor
(posterior).
Questionable prenatal indications wouldinclude checking to see
if a woman is di-lated (or more likely how much, since 2 or3or even
morecentimeters dilation isquite common weeks before labor and of
noconcern if the mother is not feeling regular
contractions that become stronger and getcloser together), to
determine if there areany changes in the cervix, to assess the
posi-tion of the cervix, or to gauge if the babywill fit.
Because the benefits of every test, assess-ment and intervention
must be weighedagainst the risks, it is important to know ifthere
are any risks to internal exams. It isoften assumed that this is a
simple, benign(albeit uncomfortable) procedure and thatit would not
be performed routinely if itdid not provide useful information.
Nei-ther is true.
What does the routine exam tell us?
The exam is limited to the specific, measur-able variables of
the present moment. Yes,it can measure effacement and dilation
ofthe cervix, as well as the position of thecervix. It can also
determine babys posi-
tion and station (how farinto the pelvis the babyis). None of
those thingsare FIXED variables. Allof them may be different
an hour after the exam.According toA Guide toEffective Care in
Pregnancy
& Childbirth, (a collectionof material from theCochrane
Database, themost comprehensive col-lection of scientific stud-ies
from around the world regarding obstet-rical care), The only reason
to perform avaginal examination would be to obtaininformation that
would be useful in deter-
mining further care and that cannot be ob-tained by a less
invasive way. In otherwords, the information must impact care ina
positive way. Routine exams dont.
Sometimes the rationale is to check theposition of the cervix.
The cervix is actu-ally the neck of the uterus. The sole pur-pose
of surgescontractionsis to drawthis neck up and out of the way of
thebabys descent. In essence, it disappearsinto the uterus. Imagine
pulling a turtleneck over your head. First itshortens (effacement)
and then itopens (dilation). At the point where thebaby actually is
able to pass through may ormay not be 10 centimeters. What is
beingmeasured during a digital exam during labor(as differentiated
from the routine, prenatalexam) is if the cervix is gonemeaning
ithas thinned, opened and sort of pulled upinto the body of the
uterus.
WHATDOESAROUTINEINTERNALEXAMTELLUS?
B IRTHPREFERENCEOPTIONS
WHAT ISTHEPURPOSEAND IS
THEINFORMATIONTHEYPROVIDEUSEFUL?VAGINALEXAMS
Sometimes anexam does provideuseful information.
I have heard many mothers ac-count stories of being told
thatthey would need cesareans be-cause they have aretroverted
(tilted backwards)
uterus or cervixmyself in-cluded. This declaration is pat-ently
absurd. Not only that, butbe the very end of pregnancy, theuterus,
now full of baby, canmove in relation to the weightof the baby and
the babys posi-tionwhich by necessity beingall parts of the same
organ canmove the cervix.
What of effacement and dilation?Isnt it important to know
whatshappening in labor?
Why? Even in labor this is a use-less bit of knowledge unless
laborhas been unusually long and thebaby seems compromised(because
knowing if a mother is 3cm or if the baby is right therehelps
determine if a cesarean orextraction is more
appropriate).HypnoBirthing mothers utilizepassive descent and
breathe the
baby down instead pushingforcefullywhich is bad for bothmother
and baby anyway. Know-ing dilation doesnt change athing. There are
other selectedsituations in labor in which aninternal exam can be
useful, butthey are very rare. There areeven fewer in
pregnancy.
[arbor&[illTransformational Hypnosis
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RESOURCES:
Haire, D., (2001). FDA approved obstetric drugs: Their effects
on mother
and baby. Alliance for the Improvement of Maternity
Services.
http://www.aimsusa.org/obstetricdrugs.htm
Lenihan JP. Relationship of antepartum pelvic examinations to
prema ture rupture of the membranes. Obstet Gynecol1984;63Wildner,
K., (2002). Terbutaline or not terbutaline. Midwifery
Today(63).
http://webpages.charter.net/mamamojo/terbutaline.html
B IRTHPREFERENCEOPTIONS
mature labor is defined as a
cervix that is progressivelydilating with contractionsthat are
longer, stronger andcloser together. Yet womenall over America are
diag-nosed with pre-term labor ata single visit because an
ex-ternal fetal monitor regis-tered contractions that themother
didnt feel, and thisinformation was combinedwith an internal exam
thatfound a cervix opened to 3cm. Thats not prematurelaborthats the
body doinga fine job of preparing tolabor effectively, and
verylikely, easily. Treating thisas true premature labor
onlycreates problems (Wildner,2003).
Then there are the things thisexam cannottell us even ifthey are
given as reasons for
doing it.It cannot predict whether ornot the baby will
fit.Pelvemitry is an imprecise
It can be important to know
if the baby is properly posi-tioned. Midwives usepalpation which
is feeingthe baby through the belly.It is safe, non-evasive
andquite accurate with skilledhands. Mothers and fatherscan be
taught how to deter-mine the babys positionthemselves. However,
timemight be better spent teach-ing mothers how to get (andkeep)
their babies in the bestbirthing position.
Also, its important to realizethat babies can and do movearound
a lot in the last weeksof pregnancy and have evenbeen known to
change posi-tion in labor. Thats hardlyinformation worth the
risksof internal exams.
What are the risks?
Can a routine internal examdiagnose premature labor?No, but it
can causeit. Asmentioned previously, pre-
bit of guess work. For one
thing, the bones of the pelvisare not fused. They are mo-bile
pieces held together withcartilage, so they have quite abit of give
for a boney struc-ture. For another, there is noway to know how big
thebaby is (or will be). Evenultrasound is highly inaccu-rate at
predicting weight(and gestational age) late inpregnancy. It can be
off asmuch as 2 weeks in eitherdirection, and 2 pounds ineither
direction. How manywomen do you know thathad to have a cesarean
be-cause the baby was too bigonly to have a perfectly nor-mal
sized, or even small,baby? Finally, the bones onthe babys head are
also notfused. This allows them toshift, so the babys head
canbecome smallerand point-iertemporarily.
Another thing most peopledont know about exams is
ARETHERERISKS?
NOTINTENDEDTOREPLACESOUNDMEDICALADVICE. EVERY
CIRCUMSTANCEISUNIQUE, ANDEACHMOTHERMUSTCOLLABORATE
WITHHERCAREPROVIDERREGARDINGINDIVIDUALCONCERNS. EACH
MOTHERASSUMESTOTALANDCOMPLETERESPONSIBILITYFORANY
ACTIONSTAKENINREGARDTOHERMATERNITYCARECHOHICES.
WWW.KIMWILDNER.COM
NOTES:
Compiled and written by Kim Wildner, 2006.
www.kimwildner.com.
that a cervical assessment is
basically an educated guess.No two people will measureexactly
the same.
One last risk is the roughvaginal exam, wherein it ispossible
for the membranesto be strippeda proce-dure in which a finger is
runaround in between the cer-vix and the bag of watersometimes
unbeknownst tothe mother. It is also possi-
ble the mother was asked,Would you like me to giveyour body a
little nudgetoward labor? Either way,informed consent was
notobtained if the mother wasnot informed that the risksof this
procedure are infec-tion and premature ruptureof membranes
(Lenihan,1984)). This can lead toinduction of labor, with all
of the risks that brings, dueto the complications nowintroduced.
Dangers cre-ated, not encountered.
