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Pelvic Exams Near Term: Benefit or Risk? Talking to Mothers About Informed Consent and Refusal

Today, S&S contributor Jackie Levine discusses the potential risks of routine cervical checks near term and how to help your clients and students be prepared to have a discussion with their health care provider about the necessity of such exams. – SM

There are some studies that show a link between routine weekly pelvic exams in the last month or so of pregnancy and an increase in rupture of membranes (ROM) that occur well before labor was meant begin, meaning the membranes have ruptured prematurely, (adding a P to ROM, for premature rupture).   The natural onset of labor may be a week or perhaps only days away, but everything is not quite ready, and if effective labor does not begin induction frequently follows.  And when induction fails, as often it will, since the rupture was premature, and the body and the baby are not ready, cesarean is often the outcome.

photo credit: flickr (link below)

Many women find that their health care providers may start doing pelvic exams at about 37 weeks gestation.  Women should consider asking their doctor or midwife whether these exams are necessary to insure the health and safety of herself and her baby, before providing consent for this invasive procedure.  When I discuss these near term cervical exams with my childbirth class students and look at the studies, mothers-to-be have to ask themselves whether the benefits of weekly exams outweigh the other risks; potential PROM, induction and the increased possibility of cesarean section.

“How do I tell my health care provider that I don’t want an exam, and not have those uncomfortable moments when my doctor or midwife thinks I’m defying him or her and not letting them do what they always do?”  That’s the common and sensible worry, that our students may have, but if we provide an opportunity to role-play with our students and clients and also provide the studies, they will feel confident about having this discussion. They will know the facts and are informed health consumers who could consider saying “Oh, I just don’t want that exam today, so can we do it next week?” They might also share that they’ve researched this topic, mention the studies and ask how routine exams week after week will help insure good health.

An older study examining the relationship between late term pelvic exams and the incidence of PROM stated:

 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 be (sic) 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.” (Lenahan, 1984.)

We have all been subtly bullied at one time or another by those in positions of authority, and it’s easy to understand the courage and confidence needed to question a caregiver. It’s a mother’s right and responsibility first to know and then to question, but confidence is the key.  We must make an effort to give real meaning to a women’s right to choose, and to the principle of informed refusal.  The American Congress of Obstetrics and Gynecology (ACOG) has addressed informed refusal several times with its membership since at least 19921, speaking powerfully  about the autonomy of the individual.  Although these writings and bulletins are aimed mainly at assuring legal protection for caregivers, they are a resounding affirmation of the legal and moral right of the patient to decide for herself.

Since the studies assert that routine exams are neither predictive nor probative, the doctor or midwife must be able to say something medically strong to counter the available studies.  When mothers have asked their providers for the reasons to do an exam, they bring a myriad of interesting answers back to class for discussion, but rarely any facts or science.  Remember, ACOG  itself published a study last year examining the basis for its care guidelines and found that “One third of the recommendations put forth by the Congress in its practice bulletins are based on good and consistent scientific evidence” ACOG, 2011) meaning Level A, and that gives us pause to consider the 70% of practices represented by Levels B and C . Care providers will often reconsider when an informed mother-to-be can ask politely and tactfully, about the science that recommends a weekly routine cervical assessment.

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-manage induction, and at worst, put our students and clients on that gurney ride into the operating room.

When a mother is motivated to discuss routine pelvic exams with her caregiver, it may be the first test of the mutual trust and respect she hopes for in that relationship.  Until that point in her pregnancy, she may not have had the opportunity, or the necessity to assert her rights as a maternity patient.  She may have refused to have a routine sonogram or two because her insurance policy would not cover extra routine assessments, but refusing pelvic exams unless there is a valid medical reason will tell her how little or much her HCP is willing to act on best evidence, give her individuated care and show respect for her informed refusal.

The first time she refuses the exam may not be an accurate opportunity for her to judge; many caregivers will let refusal ride that once, but as pregnancy nears term, most docs begin to be insistent about cervical assessment, even without medical indication. A mother-to-be can begin to learn her caregiver’s view of best-evidence care and his or her willingness to listen to her so that she will have an idea, going forward, of how best to assert her rights, with knowledge and confidence in herself, and can get support she may need in our classes.

In a Science & Sensibility post in May 2011, I talked about the importance of giving mothers the same studies that caregivers have access to.  What I said then about giving our classes the actual studies, along with discussion, still applies:

“…perhaps we need to give women a different kind of “evidence”, by giving them a look into the medical community.  If women can know more of what goes on inside the profession, if they know a bit of what the docs know, they feel a different level of empowerment.  They feel a gravitas….Not only do they know that the evidence exists somewhere out there…they see it; they own copies of the studies. They feel trusted with special information that they would never otherwise have access to. In addition to learning to trust their bodies, in addition to knowing how birth works, in addition to practicing comfort measures, they learn about what goes on behind the scenes.  It expands their sense of control and choice. “  

Refusing to have routine pelvic exams in those last weeks of pregnancy is a real opportunity for our students and clients to learn how to ask for, even insist on, best-evidence care for themselves and their babies.  It’s certainly worth a try, and we can support them in the last weeks in a positive way with lots of opportunity for role-play and discussion as they report back to class and share their experiences with informed refusal.

How do you bring up the topic of regular cervical exams for women who are not in labor?  Do you talk about this with your clients and students?  What are your favorite resources for presenting this and facilitating discussions?  Have your students shared stories about their experiences.?  Are you a health care provider?  What are your feelings on routine pelvic exams at the end of pregnancy?  Share your thoughts in our comment section. – SM

References:

ACOG: Ethical dimensions of informed consent: a compendium of selected publications, ACOG Committee Opinion 108. Washington DC, 1992.

ACOG Committee opinion. Informed refusal. Number 166, December 1995. Committee on Professional Liability. American College of Obstetricians and Gynecologists. et al. Int J Gynaecol Obstet. (1996).

ACOG Committee Opinion No. 306. Informed refusal. ACOG Committee on Professional Liability, Obstet Gynecol. 2004 Dec;104(6):1465-6.

Lenahan, JP Jr., Relationship of antepartum pelvic examinations to premature rupture of the membranes. Journal Obstetrics Gynecology 1984, Jan:63(1):33-37.

Levine, J. (May 31, 2011) A Lamaze Story. Retrieved from http://www.scienceandsensibility.org/?p=2954

Vayssière, C. Contre le toucher vaginal systématique en obstétrique Gynécologie Obstétrique & Fertilité, 2005, Volume 33, Issue 1, Pages 69-74.

Wright JD, Pawar N, Gonzalez JS, Lewin SN, Burke WM, Simpson LL, Charles AS, D’Alton ME, Herzog TJ, Scientific Evidence Underlying the American College of Obstetricians and Gynecologists’ Practice Bulletins, Obstet Gynecol. 2011 Sep;118(3):505-12.

photo credit: www.flickr.com/photos/nathansnostalgia/498100786/

Cesarean Birth, Childbirth Education, Do No Harm, Evidence Based Medicine, Guest Posts, Healthy Birth Practices, Healthy Care Practices, informed Consent, Maternity Care, Medical Interventions, Push for Your Baby, Uncategorized , , , , , , , , ,

  1. avatar
    b
    November 2nd, 2012 at 07:38 | #1

    Is there any evidence regarding pelvic exams past term, and/or post-dates? I know several mothers who planned VBAC but ended up selecting RCS in part due to their “lack” of cervical change as they approached 42 weeks.

  2. avatar
    Meghan
    November 2nd, 2012 at 07:53 | #2

    One of the things that’s hard about being a provider when you’re doing EBP is that a lot of the things you do are against conventional wisdom, and the patient (or her family) may feel like she’s not getting “everything” done. When I was still doing births, I did not check my patients routinely until they were post-dates (41+2 because of the protocols of the practice), and then mostly to make a plan for what we would do, if anything. But patients would frequently ask why I wasn’t going to check them, or ask for exams, and when I explained my reasoning, many family members would say, “Well, that’s not what my doctor said.”

    It’s frustrating to eternally be fighting against the non-EBP that prevails, and honestly — it’s the woman’s body, and if she wants an exam, I’d do one. But I always asked her what information that would give her, and how she would feel if she’s not “favorable”. About half would opt against the exam then.

  3. avatar
    Dr. Semra Ozer
    November 2nd, 2012 at 10:53 | #3

    I don’t think that it is necessary to make any pelvic exam unless there is a reason to do one. NO CONTRACTION NO BIRTH. So, what information gives you a pelvic exam? We all know that she will give birth soon. An exam can’t tell you “how soon”! :-) I personally don’t do. If a patient asks me why, I say this. But here in Turkey, I it happened only once or twice in 4 years.

  4. avatar
    Shawnette Fox
    November 2nd, 2012 at 11:33 | #4

    My favorite wisdom to impart to clients came from my own midwife. After having my first baby with an OB practice, and happily taking anything they wanted to give me during prenatal care because I wanted to be part of the mom club and didn’t know better (funny,because I refused EVERYTHING during labor–but many moms focus on how they will handle interventions during birth and not think to question the ones prior), I was surprised by the things that my midwives DIDN’T do. When I came in at 36 wks and she didn’t ask me to take my pants off, I became concerned that she’d lost track of how far along I was. When I asked her if she was going to check me that day, she looked a little surprised and said, “Well, no. We don’t do that here. Frankly, we think it’s rather rude.” That siad so much to me–a caregiver respectful of your body and your humanity will not expect to be in control of either.

  5. avatar
    Jackie
    November 2nd, 2012 at 15:03 | #5

    @b

    That’s a fine question. As far as evidence specifically about exams on post-dates, I don’t know. A pelvic exam will have a certain effect on the body experiencc\ing the exam and, of course, on the giver of the exam…if you think about it, so I think we have to stay with best-evidence practice about a healthy progessing pregnancy. That evidence applies to VBAC and nonVBAC mothers alike: since no one really knows when both baby and body are ready, since the tools for assesing accurate gestational age give dicey answers, and since studies show no improvement in outcomes, but show less successful nursing and other maturationally-based behaviors in neonates induced/sectioned even after 40 weeks, there’s no compelling reason to worry about a VBAC or any other mother staying pregnant until her own unique moment of “term” arrives. To do a routine exam just to assess a cervix and decide that if there’s no change, a section is in order, is just plain bad practice. There’s no reason to do a pelvic exam unless, yup, the mother wants one and can’t be dissuaded, or there’s a medical indication. The doc who won’t wait with some patience for his/her “motherbaby” VBAC to get ready for birth naturally, who will jump at the chance to do the section on any non-medical pretext, never really meant to support that VBAC that hard anyway, I’ll wager. So even VBACs don’t need to worry if there’s nothing wrong. And if there’s nothing wrong, well there’s just nothing wrong!! And until a woman is in labor (as Dr. Ozer says, “NO CONTRACTION, NO BIRTH” in his comment to this article), a pelvic exam is useless and may have unintended consequences. Or nothing may happen at all. Is it worth the risk of those consequences to learn nothing “probative or predictive”? I thank you for that question.

  6. avatar
    Jackie
    November 2nd, 2012 at 15:07 | #6

    @Dr. Semra Ozer
    Well, I send you gratitude, Dr. Ozer for that elegant, simple and lucid comment. “No CONTRACTION, NO BIRTH” . Ah, if only!! Thanks again.

  7. avatar
    Jackie
    November 2nd, 2012 at 15:42 | #7

    @Meghan
    We all can only hope, even as EBP may go against the “conventional wisdom” that colors every practice, that more and more it will become the standard for all practitioners. The Obama administration has devoted some $s in the health care bill to ‘evidence-based’ care implementation… sorry not to have the citation about that at hand. No matter how daunting the monolith of “opionion-based” evidence, you supported and cared for one-woman-at-a-time in the light of EBC, and the value of that is reflected in the health of the women and babies who were your clients. I think that voices like yours proliferate.

  8. avatar
    Chan McDermott
    November 2nd, 2012 at 15:52 | #8

    @Dr. Semra Ozer
    1. I appreciate Meghan’s comments about the challenges for health care providers doing EBP — it’s an education process all around, I guess — I encourage HCPs to partner w/ childbirth educators to facilite this education!
    2. I loved Dr. Ozer’s sensible, straight-forward post!

  9. November 2nd, 2012 at 16:02 | #9

    For any intervention, vaginal exams in the last month included, the question is “what are you going to do with the information you obtain?” A report that there IS some dilation may make some women too optimistic of imminent labor. A report of no change may disappoint others. Why set yourself up for that emotional roller coaster, aren’t the hormones enough? lol I like to emphasize that exams do NOT indicate when labor is going to start. They’re just a progress report of what the cervix has done so far. In the rare case that a woman truly wants an exam in the last weeks of pregnancy I like to review that the number associated with dilation is just one of MANY factors that reflect the changes or not going on. Instead of a woman being terribly set back by hearing “nope, no dilation” she can be educated to ask about softening, about position of the cervix and how low the baby is relative to her ischial spines. In this way she is at least a partner in the discussion.

  10. avatar
    Jackie
    November 2nd, 2012 at 16:46 | #10

    @Joni Nichols
    You have hit on the most important piece of info for a mother-to-be when routine exams loom… it is, as you say, “exams do NOT indicate when labor is going to start”. Ever hear an OB explain exactly what it is that a routine pelvic exam actually DOES do? Your analysis of this mainly wrong-headed conventional care is just what every motherbaby needs to have if she is to be, as you say, ” a partner in the discussion” with her caregiver.

  11. avatar
    Kate
    November 2nd, 2012 at 19:24 | #11

    What about exams done around the 20-22 week mark? I had two hospital based midwives at two different facilities and with two different pregnancies both do internals at that point in the pregnancy. I had no previous history of any issues and it was actually the first prenatal visit for each pregnancy (and the last with that care provider!). I fail to see a necessity for that, do you have any insight?

  12. avatar
    JudyC
    November 2nd, 2012 at 22:44 | #12

    @Dr. Semra Ozer
    You are so right Dr Ozer. As a caseload and homebirth midwife I do as few vaginal examinations as possible, antenatal, in labour etc. There HAS to be a reason to do one, it has to be something which will affect the care of the woman.

  13. avatar
    Jackie Levine
    November 3rd, 2012 at 07:35 | #13

    @Kate I surely don’t know the rationale for a routine exam at 20 weeks. OBs may preform a pelvic exam at the very first meeting with a newly pregnant mother, whenever that meeting occurs in the course of the pregnancy, or an exam may be one of several ways to date the pregnancy as part of accumulating clinical info if a woman’s LMP isn’t known, but your question brings up the importance of informing mothers-to-be. If women feel confident, as each test or procedure is proposed, they will not hesitate to ask what it’s for, what it will show, and what are its risks and benefits. That should be the basis for the much-to-be-wished-for mutually respectful and trusting relationship between mother and doc. She will know the reasons and make an informed consent/refusal and the doc will not coerce, condescend or even subtly demean her right to be a partner in the care of herself and her babe.

  14. November 3rd, 2012 at 23:47 | #14

    There is a principle here, “In normal birth there should be a valid reason to interfere with the natural process” (WHO 1996 Care in Normal Birth)
    As many have said, an internal/pelvic examination is an interference. Remember:
    interfere
    intervene
    interrupt
    int(o)vagina

  15. avatar
    Denise Hynd
    November 4th, 2012 at 02:33 | #15

    Another unnecessary US practice that does no happen in New Zealand, Australia or the UK and probably many other countries like Holland and the Scandanavian countires!!

  16. avatar
    Kathy
    November 6th, 2012 at 09:34 | #16

    This is Great stuff! Love learning new ways to observe labor without unnecessary, uncomfortable interventions!

  17. avatar
    Becky
    November 20th, 2012 at 15:51 | #17

    You only cite one single study that is nearly 30 years old. Are there no other research studies at all?

    As a matter of fact, there are.

    This RCT, which is only somewhat more recent, found no differences: http://europepmc.org/abstract/MED/1731288

    Here’s is one that is only 18 years old, looking at practice in Europe where apparently it was the practice in some countries to do routine cervical exams throughout pregnancy to detect preterm labor. There were no discovered benefits, but no risks identified, either.
    http://www.sciencedirect.com/science/article/pii/S0140673694928258

    This looked at twin pregnancy: http://europepmc.org/abstract/MED/8333461

    This is just a sample of easily found studies. Is there a reason why you didn’t mention more recent research?

  18. avatar
    Jackie Levine
    November 20th, 2012 at 19:21 | #18

    @Becky
    Hi, and I thank you for your question. It’s one that I’d love to spend some time answering, but I’ve already started cooking for the houseful of family coming for the holiday, and since I want to take a good amount of time thinking about my answer to you, I hope you will forgive me if I don’t get to write my answer until after Thanksgiving dishes are all washed and put away and the house is empty of kids and grandkids and long-losts who turn up at this time of year.

    So I wish you a Happy Holiday,and the same to all who read this site, and I will write next week.

  19. avatar
    Jennifer Brodie
    November 27th, 2012 at 20:09 | #19

    I’ve read the article and comments with interest and hope you do come back and respond, Jackie. Thank your for your contributions so far. Regardless of any ‘studies’, common sense (not to mention the bulk of medical evidence) dictates that one should not interfere with a natural process if not absolutely necessary. While the studies Becky mentioned show no difference with routine exams, they don’t show improved outcomes, either. In that case, the (perhaps small, but present) risks of infection and PROM and subsequent interventions should outweigh the absence of predictive or protective information obtained by VEs at any point, especially before labor. Those exams are also ‘uncomfortable’ at best for most women, and seem to reinforce the message that a woman is not really the authority over her own body and birth, but rather must submit to others’ invasive exams and evaluation of her body’s capabilities in order to birth effectively and safely. It’s one more way in which women are encouraged/expected to turn outward for permission and direction and knowledge about their own bodies, rather than turning inward to find and trust their own resources and deep knowledge, which are generally the most important sources around. I look forward to hearing more from you, Jackie, and others. Thanks!

  20. avatar
    Jacqueline (Jackie) Levine
    November 28th, 2012 at 17:50 | #20

    @Becky
    I thank those of you who addressed my comments and who are interested in this continuing discussion, for having had the patience to wait for my response. My little family had two weeks of playing host to some friends dispossessed by the East coast hurricane, Sandy, and then to a hearty contingent of Thanksgiving visitors. There were some grand and awesome births interspersed during these last weeks, too, so I have not had the time to respond until now. I thank both Becky and Jennifer Brodie for their comments.

    To begin with an answer your question, Becky, I really don’t have a good reason for not having gone to find more studies in the literature about routine pelvic exams near term, although I did cite more than one (the French study, Gynécologie Obstétrique & Fertilité 33 [2005] 69–74). The antepartum routine pelvic exam presented itself as a fountain of opportunity to investigate the relationship between mother-to-be and caregiver in the light of best-evidence maternity care. We acknowledge that “routine procedures” means, generally, that everybody gets ‘em, needed or not, and that is true of pelvic exams performed weekly. Many have said that the burden of proof for the use of a procedure that interferes with the normal progression of birth should be on the one who interferes with the norm to change it, rather than the other way around. Should we still be studying whether walking around during labor is harmful, neutral or beneficial? And yet, those studies continue to pop up, as though to prove that keeping women supine and still during labor and birth is the best and most desirable state.

    There was enough question raised for me by the studies I did look at to want to use this particular circumstance that most every pregnant woman will face, as a way to explore the manner in which mothers-to-be will learn about their caregivers’ attitudes and their own confidence when the time comes for each of us to be able to question a routine procedure.

    My experience over the years has shown me that women who want best-evidence maternity care and are aware of their legal rights as “patients”, may wish to be partners with their HCPs, and to take responsibility for the care that affects themselves and their babies. But in doing so, they may be treated badly. There was a day when an OB would say to a mother who questioned a procedure: “What, are you a doctor now?” Nowadays, everyone has access to the internet and to some very good information, so most docs take a less jaundiced view of the informed patient, but we all know that in maternity care, there is a wider gap between best-evidence care and the protocols that docs follow routinely.

    The routine weekly pelvic exam is just a perfect procedure to use for investigation…done before labor, at a routine visit, in an atmosphere without the stress of deciding something during labor… that can give mothers-to-be an inkling of how things really shake out in the relationship with the caregiver. A secure knowledge of best-evidence maternity care and of the right demand it, provides a “place to stand”, a security that can allow mothers-to-be to make informed decisions for themselves and their babes from a position of confidence. We wish that all mothers might enjoy that relationship of mutual respect with the caregiver. That makes for an atmosphere that can have a very positive effect on birth.

    I am flattered by your good words, Jennifer, encouraging me to continue writing about this stuff, and I learn daily from responses like yours. Pelvic exams have their place, no doubt, but your analysis of such procedures they may reinforce mistrust her own body and the helplessness that a women may feel in the caregiver relationship is right on. I have three children and faced those feelings along with many other women, I am certain.

    Pelvic exams in general may be falling out of favor as research continues. Here’s something that addresses routine vaginal exams for the well-woman visit:
    From Medscape Medical NewsPelvic Exams Still Common Despite Lack of Scientific Support December 12, 2011 — US physicians routinely conduct annual pelvic examinations on women despite a lack of scientific evidence supporting their use, according to a study published in the December 12/26 issue of the Archives of Internal Medicine.
    Analía R. Stormo, BS, and colleagues from the Division of Cancer Prevention and Control, US Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, and researchers from the Soltera Center for Cancer Prevention and Control Research, Tucson, Arizona, reviewed data from the 2009 DocStyles survey of 1250 US internists, family practitioners, general practitioners, and obstetrician/gynecologists.The physicians were asked how often they performed pelvic examinations for each of the following reasons: ovarian cancer screening, other gynecological cancer screening, as a requirement for starting oral or hormonal contraception, to screen for sexually transmitted infections, or as part of a well-women exam.
    More than half of all physicians reported conducting routine pelvic exams as part of a well-woman exam, with 98.4% (246/250) obstetrician-gynecologists saying they conduct such tests routinely, 89.5% (545/609) of family practitioners or general practitioners reporting this as the rationale for routine testing, and 54.0% (211/391) internists reporting this reason for routine pelvic exams. The authors considered the exam “routine” if the physician answered he or she would employ the test “always” or “most of the time.” Obstetrician-gynecologists were most likely to conduct pelvic exams for any of the reasons provided in the survey (71.6% – 98.4%), followed by family practitioners and general practitioners (55.2% – 89.5%). Internists were least likely to do so, with a low of 29.7% reporting routine pelvic exams to screen for ovarian cancer, and a high of 54.0% using the screening for well-women exams.
    “[U]se of pelvic examination for these purposes is not supported by scientific evidence and is not recommended by any US organization,” the authors write. Conducting such exams unnecessarily is not without problems, the authors note, particularly when used for early ovarian cancer detection.”The accuracy of pelvic examinations for early detection of ovarian cancer is poor,” with a false-positive rate of 98%, the authors write, leading to “overtesting and undue anxiety.”In addition, an invasive pelvic exam for sexually transmitted disease or before prescribing hormonal contraceptives may discourage women from seeking contraceptives or deter women from routine screening for sexually transmitted infections, the authors write.Physicians in the survey were randomly selected from the Epocrates Honors Panel of 156,000 US physicians to match the proportion of physicians in the American Medical Association Physician Masterfile by age, sex, and region. Most were men (70.2%), white (74.3%), and in a group practice (63.4%).Traditionally, pelvic exams were performed in conjunction with an annual Papanicolaou test for cervical cancer, but in 2003, the American College of Obstetricians and Gynecologists recommended the screening be reduced to once every 3 years if a Papanicolaou test accompanied by screening for human papillomavirus is negative.
    The research is supported in part by an appointment to CDC’s Research Participation Program, administered by the Oak Ridge Institute for Science and Education through an interagency agreement between the US Department of Energy and the CDC. Arch Intern Med. 2011;171:2053-2054.

    I love this passage from Jennifer Block’s wonderful book “Pushed: The Painful Truth About Childbirth and Modern Maternity Care, pp12-13: “It’s not uncommon for a woman’s water to break hours before contractions begin. This is labeled PROM, short for either prelabor rupture of the membranes or the more judgmental premature rupture of membranes. There is a label because there is a concern: The membrane holding the amniotic sac and ‘mucus plug’ that rests at the base of the cervix protect the fetus from exterior microbes. The worry is that if labor doesn’t quickly progress following loss of that protective barrier, infection will set in. Since the 1960s the ’24-hour rule’ has held: birth must happen within 24 hours, one way or another. Accordingly, in order to beat the clock, artificial oxytocin is given to stimulate contractions.”Hodnett co-authored a study of 5000 women in 1996, … the largest to date, and found no increase in neonatal infection in PROMs that were watched for up to 4 days after rupture. The vagina is a nearly airtight passageway, so loss of the plug and rupture alone don’t significantly increase the risk of infection, she explains. Vaginal exams, however, do, and should be kept to a minimum following rupture. Hodnett’s research protocol prohibited them. But that caution is not usually heeded, she tells me. Indeed, women typically experience several vaginal exams during labor to determine how many centimeters the cervix has dilated, sometimes by different practitioners. …”Most women, some 60%, will go into spontaneous labor within 24 hours of their water breaking, and 95% will begin labor within 74 hours. Nevertheless, hospital protocol is usually clear on the 24-hour rule. And in some hospitals and among some practitioners, the window is 12 hours or less. “We feel a sense of pressure to get things moving,” Laura Riley in Boston told me. “My own practice is that I give people about 8 to 10 hours.” What these time limits mean is that once a woman’s water is broken–spontaneously or deliberately–she is on deadline. …”The study referred to above is Mary E. Hannah et al., “Induction of Labor Compared with Expectant Management for Prelabor Rupture of the Membranes at Term: Term PROM Study Group,”New England Journal of Medicine 334, no. 16 (1996): 1005-100

    I just want to know that a woman can have access to the the information and the studies that define best-evidence care, have the confidence to demand that care, and count on a conservative mindset from her caregiver…not to interfere without medical indication, to eschew routine procedures, and to respect the process and majesty of healthy normal birth. Whew…that’s a lot to ask.

    So thanks to you, Becky…you are right to question the position I took, and again, to you Jennifer. Bless inquiring minds!

  21. avatar
    Anon
    July 18th, 2013 at 05:31 | #21

    Pelvic exams are better at helping derermine presentation. Leopolds exam is not always reliable, but an abdominal pelvic exam can better tell you what the presenting part is. As well as dilatation, effacement, station, pelvimetry, an position. A pelvic exam can always rule out infections like herpes, warts, molluscum, and GBS colonization. If a client lives an hour away from the birth center, a pelvic exam along with knowing her parity better helps you explain to her what threshold to consider coming in. A pelvic exam helps decrease the incidence of unknown surprise laboring breech that still happens today with to many midwife led labors…

    http://community.babycenter.com/post/a43310572/double_footling_breech_delivered_vaginally

  22. avatar
    jacqueline levine
    July 18th, 2013 at 17:35 | #22

    I’m glad to have your input on this topic. There certainly are good reasons for pelvic exams and you have named a few. I do not condemn every pelvic exam.

    The aim of the article was to explore whether there’s good evidence for ROUTINE WEEKLY PELVIC EXAMS FOR EVERY WOMAN starting at about 36 weeks. These weekly exams begin at about the same time that the Group B strep test is also (routinely) done. There is no good evidence FOR giving an exam every week. If there is no probative or perdictive value to an exam each and every week for each and every woman, but there is a risk, however slight, that those exams might cause membranes to rupture, induction on an unready cervix to fail and a follow-on cesarean to be the end result…why risk a surgical birth on an unready fetus for a routine procedure that has no medical reason? Not every baby is ready to function outside in the world at 36, 37, 38, 39 or even 40 weeks. The baby plays the part of the initiater of labor…if the baby isn’t ready to give the signal for labor to commence, then the baby is not ready to be born, even if only a few days separate that baby from readiness.

    How many women feel comfortable refusing a routine exam? Is it easy to do? Is it easy to ask the reason for the exam? Suppose women don’t know the risk, however slight, and cannot weigh their choice to say yes or no since they have no facts? Does any doc discuss the possible negatives of the routine exam? And midwife -lead labors miss breech presentations? Without ultrasound, no one can be sure… babies do move around, therefore pelvic exams by either OB or midwife can miss a breech Than why the exam at all?

    There is no real benefit to a weekly pelvic exam for each and every woman without medical reason. A careful and respectful pelvic exam done with expressed permission when a woman is already in labor may help a caregiver and the mother-to-be herself get some information, so do not think that I am condemning every pelvic exam. An exam for a perceived problem can answer questions. Informed consent for pelvic exams with medical indication are fine, but to give them to any and all every week…nothing do with station or dilation or warts or “parity” or GBS status or herpes or trichimonas or whatever..and at 36 weeks, babies still turn from breech… just exam after exam starting at 36 weeks…and on and on.

    Let’s opt for no routine maternity care! Informed refusal and informed consent for all! Women deserve to get optimal maternity information from their caregivers, and then to get the best-evidence care they deserve for best health results for themselves and their babes. That’s our aim, isn’t it?

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