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In Midwifery Matters, Issue No. 81, Summer 1999
Chris Warren
HIS HANDS rested lightly on my shoulders, I could feel his breath in my hair. He was invading my personal space. It was fine.
No, not the start of a Mills and Boon romance, but the end of an osteopathy session. With love, care and professionalism, my osteopath helps me sort out my neck or shoulders.
Vaginal examinations are that much more intimate. Why do we do them? How do we do them? Surely not because we always do them, that way? I don't mind vaginal examinations but I realise that many women dread them.
"Vaginal examinations are often a source of anxiety both for midwives and the clients they care for. Many women find them distressing, uncomfortable and embarrassing, and such emotion is often sensed by midwives. The intimate invasiveness of vaginal examinations may cause more mental anguish than its associated physical discomfort." (Devane, 1996)
Vaginal examinations can estimate the dilation of the cervix, confirm the presenting part, estimate the level of the presenting part, diagnose the position of the baby and determine whether the membranes are intact.
But how often do we need that information? Are there other ways of finding out about progress? There is general behaviour, vocalisations (McKay and Roberts, 1990), abdominal palpation as well as rate and strength and duration of contractions. Lesley Hobbs (1998) describes the progression of a thin purple line up the natal cleft that is associated with cervical dilatation. Does anyone know of any others?
The BMA has accepted that there is no indication for routine vaginal examination antenatally and I would go further and say there is no place for routine vaginal examinations in any labour. I believe vaginal examinations should be undertaken only when there is doubt about the clinical findings/symptoms/situation and when the information gathered is necessary or likely to be of use in informing the next decision. Thinking back to occasions when I have, with consent, examined a woman vaginally, I came up with the following varying scenarios:
The first does not apply to me anymore, Jess is nearly nine and stopped breastfeeding soon after her fourth birthday, but that's another story.
Maggie greeted me with: "I need to know how dilated I am, but don't tell me I'm only 1cm". This was her first labour and it had started five hours ago. Seven years earlier her son had been born by elective caesarean operation. I stretched a point and made it 1.5 cm; she wanted to go to hospital but decided to have a bath while I drank the obligatory cup of tea. An hour in the bath, an hour lying on her side on the bed, back to the bath for ¾ hr and the pushing vocals indicated full dilatation. Hospital was not mentioned and one and a half hours later, Roxanne was joyfully born, four and a quarter hours after her mother's cervix was only 1.5 cm dilated.
Lydia wanted her second baby to be born in hospital and booked for a DOMINO. She sounded a bit pushy on my arrival, but the vaginal examination showed a cervix dilated to 8 cm and not too stretchy. So we went in and made it with 35 minutes to spare.
Niall did not make it. 12 hours prelabour and two vaginal examinations when I felt a typical multips os, followed six hours sleep and four hours of very strong contractions, no VEs and a large baby. Val phoned him once she had strong contractions. Maybe she needed to know she could do it without him.
Jenny seemed to be making heavy weather of this second labour and I was uncertain if she was progressing as fast as I'd first thought. My preparations for the birth were complete, equipment on a tray, gas bottles connected and checked but if this was early labour different strategies were needed to conserve energy. A vaginal examination - just 2 cms. Six hours later the membranes ruptured spontaneously and there was fresh dilute meconium and a second invasive vaginal examination showed progress to 3 cm. We transferred in where external fetal monitoring concerned me but not the staff who were used to it. Nine hours later, three more VEs, some rolling around on a birth ball, supportive offer (or threat) of an epidural and Bengy emerged with Jenny pushing, as she wanted, on her hands and knees.
I'm still waiting for my first undiagnosed breech.
OK. Sometimes I am misled by vocalisations and I do not consistently find the purple cleft line; I believe that sometimes a vaginal examination is necessary and should be done as sensitively as possible.
The doctors (RCOG 1997) have produced some sensible guidelines which could form the basis of good practice:
"it is essential for the gynaecologist to consider what information will be gained by the examination and to consider whether this is a screening or diagnostic procedure and whether it is necessary at this time.
"Most women will accept vaginal examination if the necessity for the procedure is explained and the examination is performed by a doctor who is skilled, sympathetic and gentle.
"Verbal consent should be obtained prior to all pelvic examinations.
"Chaperone offered…. Private, warm and comfortable changing facilities, closed room that can not be entered while the examination is in progress and not interrupted by …bleeps or people."
It is salutary that this report stresses questioning the necessity for doing a vaginal examination and states:
"The conduct of the first vaginal examination may influence the young woman's confidence in and uptake of gynaecological and family planning services for the rest of her life. Consider the necessity…and its likely productivity"
Adopting these guidelines and the philosophy behind them would reduce the number of vaginal examinations during birth and improve the `how' as well. I shudder to confess that I have used some of the distancing strategies reportedly commonly used by midwives (Bergstrom et al, 1992): "I'm just going to examine you, let your legs flop outwards, that's it, relax now". Now I make and maintain eye contact. How else can you tell the woman's response? I stop if she winces and ask where it is hurting, or explain what I'm finding and why, if the cervix is posterior, I'm having to delve a little deeper. Linda Bergstrom's rigorous research showed that vaginal examinations were performed in a ritualistic manner and in a way that demonstrated the power of the caregiver over the woman. While I am sure I have never said: "You'll feel me touching you, Sweetie", I found it a fascinating study, well worth re-reading. The article focuses on the second stage of labour and Murray Enkin suggests that we need to recognise: "that repeat vaginal examinations are an invasive intervention of as yet unproven value." (Enkin, 1992). Is this is so for all VEs in childbirth?
Like many others, I try to ensure that my practice is evidence based but research doesn't show much. Declan Devane declares that he is unable to find any research showing the necessity for VEs. Why undertake an unwelcome procedure if the information you are likely to get is not needed to inform your practice or to be necessary for subsequent decision making?
In the Association of Radical Midwives, a long time ago, we used to try things out on each other. Have we come too far to learn gentle, connected, with-woman vaginal examination on each other? I don't want to put anyone off coming to meetings, participation is always voluntary and we need to talk about things first and then decide on the best way forward.
As midwives, like osteopaths, we are `invaders of privacy,' so can we ensure we do so only when necessary and in the best possible way? Can we recognise vaginal examinations as interventions of unproved value?
With love, care and professionalism, we can.
Bergstrom L, Roberts J, Skillman L et al (1992). ` "You'll feel me touching you, Sweetie": Vaginal examinations during the second stage of labour', Birth, 19, 1, 10-18.
Devane D (1996). ` Sexuality and midwifery', British Journal of Midwifery, 4, 8, 413-416.
Enkin M (1992). `Do I do that? Do I really do that? Like that?' Commentary, Birth, 19, 1, 19-20.
Hobbs L (1998). `Assessing cervical dilatation without VEs Watching the purple line', The Practising Midwife, 1, 11, 34-35.
McKay S and Roberts J (1990). `Obstetrics by ear - Maternal and caregivers' perceptions of the meaning of maternal sounds during second stage of labour', Journal of Nurse Midwifery, 35, 5, 266-273.
RCOG (1997). Intimate Examinations, report of a working party. The Royal College of Obstetricians and Gynaecologists, RCOG Press, September 1997.
Ed. IK 14th June 1999
AH updated 16 September 1999