From MIDWIFERY MATTERS, Issue No.108, Spring 2006
The importance of delivering evidence based midwifery care is now a pretty well
understood and established norm. However, from time to time midwives have to
deal with occurrences that have never been reported in literature, or researched.
Cervical reversal falls into this category. The term cervical reversal is relatively
new, first coined, I think, by American midwives. This happens when one midwife's
vaginal examination, for example 8 cms, turns out to be 5 cms when done by another
midwife or doctor, usually hours later! It happens quite frequently. The frustration
is that it is a phenomenon that does not appear in any midwifery or obstetric
text book. No research exists to explain it. In practice it is blamed on poor
vaginal assessment skills because: "cervices do not get smaller".
A few months ago I was prompted to explore this further following an incident at work. A community midwife had handed over the care of a woman at a stage of 8 to 9 cms, with a persistent anterior lip and strong urges to push. Hours later the woman had an emergency LSCS for lack of progress. The doctor had assessed her cervix to be only 5 cms. This was communicated to the midwife with the suggestion that she needed to be on delivery suite full time to update on her vaginal assessment skills!
Gathering information was difficult, relying mostly on an internet search of world wide midwifery archives. I found the first article on the website www.gentlebirth.org. This is the American equivalent of ARM's midwifery archives. Listed among the topics was cervical reversal. The site is hosted by a homebirth midwife called Ronnie Falcao. Homebirth midwives write in to discuss their birth experiences and many other childbirth issues. The site directed my attention to the Midwives Alliance of North America (MANA).
MANA is an organisation of independent midwives in North America. They are
a very proactive group and are involved in varied childbirth research. Interestingly,
they have been collecting statistics on cervical reversal since the 1990s. The
process started when one of their midwives transferred a woman from home to
hospital, at 9 cms. However the obstetrician found the woman to be only 5 cms.
Not believing this the midwife examined the woman again while doctor was out
of the room; yes you guessed it, 5 cms. Soon other midwives were reporting similar
experiences. MANA added cervical reversal to their data collection form.
MANA's first report was on 9,000 births (MANA, 1998). Cervical reversal was
reported by 107 midwives and occurred in 234 women (2.6%). Midwives found that
the most common factors associated with reversal were: home to hospital transfers;
a swelling anterior lip; an ill fitting presenting part; following membrane
rupture; anxiety; lack of continuity of carer; and contractions stopping. We
are all aware that all the above may affect a woman's progress in labour, but
we do not seem to accept that they can be associated with a cervix closing down.
Vaginal examinations are subjective. It is deemed unprofessional to question another person's clinical judgment about something so subjective. The 'holier than thou' attitude has no place in midwifery care. Midwives need to feel confident and supported in their practice. Encourage a life long learning, and be proactive in questioning certain accepted beliefs.
We are conditioned to accept obstetric assumptions that define labour and delivery
by the so called 3Ps. The Passenger (baby), the Passages (pelvis and vagina)
and the Powers (strength of uterine contractions). Ina May Gaskin (2003) challenges
the law of the 3Ps and discusses an alternative, which she calls Sphincter Law.
Sphincter law explains optimal psychological conditions for labouring women,
which in turn will enable the 3Ps to function well, and suboptimal conditions
which can cause the cervix to close down, or labour to stop (to be enlightened
on the subject buy or borrow Ina May's book). Sphincter Law manifests itself
in the following ways:
o Sphincter muscles of both anus and vagina do not respond on command.
o Sphincter muscles open more easily in a comfortable intimate atmosphere where
a woman feels safe.
o The muscles are more likely to open if the woman feels positive about herself;
where she feels inspired and enjoys the birth process.
o Sphincter muscles may suddenly close even if they have already dilated, if
the woman feels threatened in any way.
I set out to learn about cervical reversal. In the UK midwifery databases I
found nothing. Maybe there is, and I have not yet found it. lf someone is looking
into it, or has produced some work, I would love to hear from them. In the mean
time I have started a yahoo group to be a discussion forum for Cervical Reversal.
This is to generate interest and collect information for statistics or/and hopefully
research. I have a dream!
The group home page location is:
http://uk.groups.yahoo.com/cervicalreversalUK
The group emailaddress:
cervicalreversal/uk@yahoogroups.co.uk
REFERENCES
Gaskin IM. (2003). 'Sphincter Law', in Ina May's Guide to Childbirth, New York
Bantam books, 2003, 167-182.
MANA (1998). Report on Cervical Reversal, MANA Newsletter, 16, 2, 16-17, March
1998.
www.gentlebirth.org web site
Updated LW October 3, 2006