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vaginal exams

ALL OF THOSE VAGINAL EXAMS

The other day I posted the following quote on LinkedIn:

 

“You do not need a vaginal exam to have a baby. I am serious. They will still come out.”

                                                                               ~ Mama Birth     http://mamabirth.blogspot.com/

 

 

My new friend,  Jacqueline Levine  , Childbirth Educator/Lactation Consultant at Planned Parenthood, Greater New York City Area, contributed the following in response:

 

• There are some studies that show a link between routine weekly exams and an increase in ROM before labor was meant begin…meaning “PROM”, premature rupture of membranes. Sometimes the natural onset of labor was meant to be only a week or perhaps just days away, but everything was not quite ready. When things aren’t properly ready and labor doesn’t begin because rupture was provoked by the consequences of repeated routine exams, induction must follow, and when that fails as it often must…since the rupture was PREMATURE, right?…cesarean is the only outcome, since a Bishop score to assess cervical readiness at that point is moot. The toothpaste cannot go back into the tube.

Is it worth it to accede to weekly exams when they are weighed against the increased possibility of section? Mothers will ask “Well how do I tell them I don’t want an exam and not have those uncomfortable moments when my doc thinks I’m defying him/her and not letting him do what he always does…” That’s always the problem, but if we role-play with our clients and give them the studies, they often feel confident enough and protective of their health enough to say something like “Oh I just don’t want that exam today, so can we do it next week?” or they can say that they’ve researched this pregnancy very well, mention that there are studies, and ask how the exam will help their health. What will it tell the doc? It’s their right to know and to question, but confidence is the key. We have all been subtly bullied at one time or another by those in positions of authority.
s I believe that we must make an effort to give real meaning to a women’s right to choose (!). Since these exams are neither predictive nor probative, the doc must be able to say something really medically strong to counter the studies. They will often back down…

Here are just a few studies I found:
Relationship of ante partum pelvic examinations to premature rupture of the membranes. Lenahan, JP Jr. Journal Obstetrics Gynecology 1984, Jan:63(1):33-37. I quote from the abstract: “In the 174 patients on whom pelvic examinations were done weekly starting at 37 weeks gestation, the incidence of PROM was 18%, which was a significant increase (P=.001). The primary cesarean section rate was comparable in both groups with PROM; however, the overall primary cesarean rate when PROM occurred was found to be twice that of the remaining population. The study suggests that routine pelvic examinations may a significant contributing factor to the incidence of PROM . Women with uncomplicated pregnancies were randomly assigned to one of two groups. The author theorizes that the probing finger carries up and deposits on the cervix bacteria and acidic vaginal secretions capable of penetrating the mucous plug and causing sufficient low-grade inflammation or sub-clinical infection to rupture membranes. ‘It would therefore seem prudent to recommend that no pelvic examinations be done routinely in the third trimester unless a valid medical indication [sic] exists to examine the cervix … especially since the information gained from these routine examinations is often of little or no benefit to either the physician or the patient.’

Here are others: Histologic chorioamnionitis in pregnancies: implications in preterm rupture of membranes. Department of Obstetrics and Gynecology, Univ. of New Mexico School of Medicine, Albuquerque, and: Medscape Medical News Pelvic Exams Still Common Despite Lack of Scientific Support Arch Intern Med. 2011;171:2053-2054.

Again, women should be able to weigh the risks of routine exams against the possibility of that cascade of interventions that follow on with PROM, interventions that will, at the least, lead to an uncomfortable and harder-to-mange induction and at worst, put our clients on the gurney ride into the operating theatre.

Many thanks to Mama Birth and Jackie !!!

Premature Rupture of Membranes & Repeated Pelvic Examines

Jacqueline Levine, a sister doula and occasional writer for  Lamaze research blog Science and Sensibility, gracefully gave me permission to post her comments about premature rupture of membranes… or PROM.

Very eye opening!!!

Hello all…There are some studies that point to the fact that repeated pelvic exams in the last month can irritate the membranes and lead to PROM at term (premature rupture of membranes), meaning labor is immanent, and mothers are close to their “due date”, but pelvic exams insert an artificial factor into the circumstances that lead to the healthy beginning of effective labor. Onset of labor may be just a few weeks or days away, but if waters break and labor doesn’t ensue, although mom is almost-but-not-quite ready, they must induce. Pelvic exams are not predictive or probative and unless there is compelling medical reason, should not be done week after week at the end of the last month. Being able to say to a mom that her cervix is softening but still not opening is nice, or to tell her that she is 50% and 1 cm is interesting indeed, but what really does it do for the process? Does it tell her when she’ll go into labor? Not bloody likely! If enough acid in the vagina is pushed to migrate upwards, or mother’s flora (or yikes! foreign germs from the glove covering the inserted hand) are forced up towards, and finally permeate the mucous plug to irritate and eventually disturb the integrity of membranes, they will respond by breaking. Now we have put another whole category of mothers onto the c-section express.

Here are some studies:
* Obstet Gynecol. 1984 Jan;63(1):33-7. Relationship of antepartum pelvic examinations to premature rupture of the membranes.

Lenihan JP Jr*
* Obstet Gynecol. 1987 Dec;70(6):856-60. Histologic chorioamnionitis in pregnancies of various gestational ages: implications in rupture of membranes.Perkins RP, Zhou SM, Butler C, Skipper BJ. SourceDepartment of Obstetrics and Gynecology, University of New Mexico School of Medicine, Albuquerque.

* vaginosis and its implication in preterm labor and premature rupture of membranes. A review of the literature. Reynolds HD. Source Yale University School of Nursing, New Haven, CT

There are more studies. This knowledge has been around for a while. When, d’ya suppose, will caregivers heed some evidence-based stuff? Here’s the answer, I guess:

* Do the Medical Policymakers of Maternity Care Resist Changing Their Protocols to Reflect Best-Evidence Scientific Practices for Childbearing Women?

Olatunbosun OA, Eduoard L, Pierson RA. Physicians’ attitudes toward evidence based obstetric practice: a questionnaire survey. Br. Med. J. 316, 365–366 (1998).*
Abstract: In 1998, a questionnaire mailed to family physicians and obstetricians found that only 40% felt that evidence-based medicine was “very applicable to obstetric practice”. Concerning comments from this survey included “obstetrics requires manual dexterity more than science”, “evidence-based medicine ignores clinical experience”, and that following guidelines could result in “erosion of physician autonomy”. These views were described as obstacles to the adoption of evidence-based practices, and the authors recommended emphasis of critical analysis of the literature as part of medical education.”

Let’s let our mothers know about this and Bishop scores and give them the facts so that they can refuse pelvic exams and other procedures except for compelling medical necessity, and wait to get exams until they are well into labor and need to know whether they should be admitted!! There…I’ve said it!!!

Thank you, Jacqueline!!!

If you wish to weigh in….send your comments to

KennyShulman@aol.com