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Friday, October 29, 2010

The psychology of vaginal exams

Most women would never consider the state of their cervixes as having anything whatsoever to do with their brain. However, for many, this isn't entirely untrue.

Many people think that a vaginal exam in late pregnancy is just part of the old routine when it comes to maternity care. For probably a large portion of them, it is - but it doesn't mean it tells you (or the doctor) anything at all.

I've heard so many people ask "Will I go into labor soon?" after a 37-week cervix check. Or they're losing bits of mucus plug after an exam and think it's because they're dilating (which they might be), likely because the doctor's poking and prodding dislodged something. Many are downright depressed to hear that nothing's going on at all and some are elated to be dilated to 3 at 36 weeks because they think labor is coming soon - and maybe because their doctor said, "Oh, you'll go early." Wishful thinking, at best.

I ran across a very informative article by Robin Elise Weiss that outlines the "myth" of the vaginal exam and what it can (and can't) be good for. I've also survived three pregnancies and different stages of dilation in late pregnancy that tell me one thing: being dilated (or not) towards 40 weeks doesn't mean squat.

Many of us, including myself during all my pregnancies, are curious to find out if there is something going on in that department. Even during my third pregnancy, when I knew dilation and effacement meant little at that point, I was anxious to see if anything was happening - because, after all, this was my third pregnancy. Things are supposed to move faster at that point, right? Wrong. I was actually more dilated before labor (at probably 36 weeks) with my very first baby. I was so excited to learn that even as a first-timer, I could still dilate early and wondered if it meant I would deliver early (after all, both my mother and I had been born before our due dates). The doctor was skeptical. (It turns out I did deliver my baby five days before his due date, thank you very much. But I doubt that had anything to do with my cervical progress when he checked me.)

If you're simply curious (and who isn't?), I doubt having one in late pregnancy is going to necessarily be a bad idea. But neither does it mean you need to be checked at every visit (barring any conditions like preterm labor, etc.). I often tell women if you are dilated, it doesn't mean you'll go into labor anytime soon, and you can be dilated for weeks and still be overdue. Nor does not being dilated mean anything - you can deliver your baby in a matter of hours or days from a depressing cervical check that convinced you labor would never happen. This has happened to me as well: at my last prenatal appointment with my second baby, I was disappointed to learn that I was neither dilated nor effaced. And yet, a week later, I was holding my daughter. So you never know.

Some women refuse them completely in both pregnancy and labor because they know the results are not always that important. I will say this: from my experience I was thankful to have them in one sense - that it could verify my baby's position. With my first, we didn't find out he was breech until probably about ten days before he was born. That uncomfortable, crappy vaginal exam ended up helping me prepare for the very real surgical birth I was about to experience and helped me process it on an emotional level. My friend, however, who also has a history of breech babies, had no idea her baby was breech while she was laboring at the hospital. "Did you have an exam?" I asked her. She said her doctor never did a cervix check on her prior to labor, which can be considered good and bad, depending on your point of view.

The state of your cervix can also play tricks on your mind while in labor, too. Dilating fast? Great! Not so fast? Guess what, you'll be submitted to probably hourly dilation checks to make sure you're moving at one centimeter per hour, that Golden Rule of Obstetrics that means "you'd better make progress, lady!" If not, then some doctors will be patient and wait for you to progress. Others will label you "failure to progress" and you might be threatened with a c-section, or they'll ramp up the Pitocin to force things along. While I've never personally had this happen, I'd think that exploring your options might be a good idea: are baby and mom tolerating labor well? Can you please please please walk around/sit on the birthing ball/change positions/do something else in order to encourage dilation? I can't say for sure whether it worked or not, but I carried a coffee can lid around in my purse for weeks before my birth because it was the approximate size of a fully-dilated cervix - and I visualized my cervix opening up, just as many birth instructors have suggested. Mind over matter! If you can go to that special place inside yourself and focus on progressing, who knows - it just might work.

That famous rule - The Friedman Curve - is a huge pet peeve of mine. We're constantly told during our pregnancies that "every woman, every labor is different!" and yet when it comes right down to it, we're not treated as if we're different. We're forced into a nice, tidy box that says that "even though everyone is different, we're going to require you to perform in labor like everyone else." A brief search on The Friedman Curve draws some scrutiny: one article states that the half-century old rule is "the ideal, rather than the average" curve, calling it an "obsolete approach to labor assessment." If that's the case, and we're living in such a technologically-advanced medical community these days, then why is everyone and their surgeon still using it?

The body is an amazing machine, and if you listen to it, it'll tell you something. Just like the urge to push, when you're going through transition, you may feel a wide range of symptoms: nausea, irritability, vomiting (also affectionately called by some, "The Seven Centimeter Pukes,") feeling emotional and crying for no reason, or shaking. With all those obvious signals, who needs a cervix check?!

For some laboring women, repeated cervical checks can actually cause dilation to slow or stop altogether, what Ina May Gaskin calls the "Sphincter Law " in her book Ina May's Guide to Childbirth. A particularly harsh or brusque doctor with the bedside manner of a goat might create an atmosphere of hostility in the room that discourages the woman from opening up and dilating further. She compares this with trying to go to the bathroom while people are watching - not very easy, and a terrific analogy of how our minds can often control even the most involuntary of our body's actions.

Not only that, but the physical ramifications of constant vaginal exams while in labor can be great as well. Repeated exams can introduce infection, and often times women are led in 'directed pushing' when they reach completion simply because they're 10 cm and "it's time." Well, not if you have no desire to push. Directed, or coached, pushing simply based on your cervical status is probably a leading cause of tearing and trauma to the vaginal area. Again, throughout labor, your body will tell you when it's time to push, and it's not necessarily the exact minute you become fully dilated. If there's one thing I could do over in my vaginal birth it would be to push when I was ready to, not just because I was complete.

It's important for women to remember that the results of a cervical check should not be something to get upset over: if you're dilated, that's great. If not, it doesn't necessarily mean you will have to be induced, sectioned, any of that. All too often women place so much emphasis on those results that they become desperate to induce their labors and get things moving, but for what?

As someone said, checking women while in labor or late pregnancy often 'makes doctors feel like they're doing something useful.'

I couldn't agree more.

Additional links:

More on Pushing
Mother-Directed Pushing: Six Reasons to Listen to Your Body During Labor


19lt70 said...

This is an excellent post. With my 6th and last baby I refused a cervical check at my last appt. b/c I knew it wouldn't tell me anything. Why be bothered? I also personally feel that the less a woman is checked in labor, the better, for all the reasons you mentioned. Often times, if birth providers are on top of things, a cervical check is not necessary. Many women indicate when the time is getting close. However, if an OB is at home or not at the hospital, it is better to know what's going on with a cervical check b/c then there's enough time to get them to the hospital. I personally feel that cervical checks can be more discouraging than helpful overall.

Anonymous said...

With my first child I had directed pushing and tore terribly. I went in for bleeding and was told induction was going to happen, well I went on my own and then at 11:30 was told no we aren't breaking water as we don't want a 3 am baby. Water broke at 11:45 and baby was born at 3 am after 90 minutes of pushing. Not an experience I want to ever relive.

My 2nd baby was stillbirth and well not an experience to have again as well. That birth was all natural till after the birth, and labor was much much different than my first which makes me think that the OB may have stimulated my first labor with some gel or something.

My 3rd labor and delivery was amazing. It was n induction after walking around 3cm 90% effaced for 4 weeks, he wasn't leaving without help. I had minimal cervical checks, one per hour maybe for 3 hours and they broke my water at 5 cm, 45 min later I push and was holding my son in minutes.

The moral for me out of those 3 births is my doctors- they listened to me. I watched my son's birth cause they noticed I was curious- and that helped immensely in pushing and knowing when to stop. Little to no tearing with e and he was a bigger baby. Yes it was medicated but that's for neck issues and as a safety measure.

The Deranged Housewife said...

I agree about the tearing - I had a bit of a cervical lip and was impatient so I agreed to be cut. Bad idea. I wonder if I had just waited - they call it laboring down - and maybe she would have slid right out - who knows?

One thing I didn't mention are epidurals - too early and it can slow labor, too late and you won't get the pain relief. But that's subject to debate and it's possible to get great pain relief and still be effective at pushing. For some it requires more use of tools to deliver and can increase the chance of tearing. I've heard a mixed bag on them as far as control you have in labor - some women can easily control their pushing and for others it's like they're zombies. Were they afraid of having difficulty placing the epidural because of your neck problems?

Isn't it funny how they said they didn't want a 3 a.m. baby and yet she was born at 3 a.m.? LOL Makes me think that no matter how hard we try, they will come when they're ready anyway. ;)

Rachel O. said...

A few weeks ago, I arrived at the hospital in labor with my third baby. When they did my vaginal exam, I was found to be 5 cm. The next contraction, my water broke. The next contraction, my babe was crowning... the following contraction, she was born. Dilation truly does not tell you when your baby will be born.