Weekly vaginal checks starting at 36 weeks? Frequent vaginal checks in labor? Does this policy give your provider important clinical information – or is this an obstetric ritual that exists simply because it hasn’t been questioned?
Vaginal checks in labor can be uncomfortable and intrusive. Amy Wright Glenn wrote a two-part series Dear OB: It’s Not Your Vagina and discussed this policy with our own monitrice, Rachel Leavitt. She reminds women:
Mothers-to-be, laboring women, pregnant friends – listen to me.
You have the right to determine who – if anyone – will put his or her hand in your vagina during pregnancy and birth. You have the right to inquire about any procedure that is being suggested as part of your prenatal, labor and delivery care. You have the right to consent. You have the right to request a vaginal exam. And you have the right to refuse one. Period.
But, is this an important piece of your clinical care? Does your provider NEED this information to provide safe care?
“We look at a lot of different signs to determine progression. We do very few cervical checks. We use signs such as change in contraction pattern, how the woman is coping, physical signs such as shaking, nausea, bloody show and moaning. You can see how a woman begins to turn inward and the ability to concentrate decreases. These are the typical things we will look for and chart. We only check when women first come in, and if they refuse, we don’t worry about it. We will also check if it has been a long time without any external signs of progression or if there is a clinical need. Again, a woman’s right to refuse is acknowledged.”
Rebecca Dekker of Evidence Based Birth examined two studies that looked at the effect of weekly checks at the end of pregnancy. Her conclusion:
I think in summary the evidence really shows that there is no benefit to doing the weekly exams. It may satisfy your curiosity or your doctor or midwife’s curiosity, but it doesn’t really have an effect on your health either way. You are asking me what’s the evidence, what references can I use when I go to talk with my doctor, and I would say when it comes to a situation like this you don’t have to give your reason why. If you don’t want the vaginal exams, either because they make you uncomfortable or you just simply don’t want them or you think they’re unnecessary for whatever reason, your reason is your own and you don’t have to explain it to anybody.
A recent study published in the American Journal of Obstetrics & Gynecology looked at the differences in outcomes between elective induction of labor at 41 weeks and expectant management until 42 weeks. The conclusion of this study was:
In a large randomized clinical trial among low risk women, we found no statistically significant differences between elective induction of labor at 41 weeks and expectant management until 42 weeks. The observed rates can be used in a process of shared decision making.
Both primary and secondary outcomes were reviewed. Read the summary here and the entire study here.
Have you wondered what those crazy pregnancy dreams mean? I had several vivid dreams during my pregnancy with my second son (sorry, Robert!) and would have loved to use this article to decipher what I was sorting out in dreamland.
Julie Revelant FoxNews.com shares a fascinating list of the most common pregnancy dreams and their respective interpretations. Water, forgetting the baby, small animals and insects, and labor and giving birth are on the list.
Why do you dream these crazy things in pregnancy? Well, there is some good news. According to Ms. Revelant’s article:
The good news is that dreams aren’t premonitions and pregnant women who have nightmares may actually have shorter labors, according to a study in the journal Psychiatry Research.
Was this true for you? Did you have nightmares and shorter labors? What dreams did you experience?
We came across an interesting opinion piece in the New York Times discussing the benefits of a conversation “placebo” – the evidence supports that substantial portion of “healing” comes from the communication and connection with the patient.
Under the Midwifery Model of Care, the conversation between provider and client is an essential component of partnership care. We agree that conversation is crucial, but would not characterize it as a “placebo” – still, the discussion in the context of the medical model to address this important relationship of trust between provider and client is a positive and worthwhile read.
Before we had treatments that could actually counteract the pathology of disease — antibiotics, chemotherapy, stents, organ transplants, transfusions — placebo was the mainstay of medical care, and in many cases it was remarkably effective.
A good example is patients suffering from vague diffuse pains with no discernible cause. Frequently my patients ask if a multivitamin will give them more energy. In the past I would say no, because there are no significant scientific studies to demonstrate this, and also because in the absence of a vitamin deficiency there’s not much for a basic multivitamin pill to do. Now I take a different approach. I say something along the lines of “Many of my patients find that they have more energy when they take a multivitamin.” I’m not lying, because many have indeed said so. Without fail, there are always a few patients who come back at the next visit and swear they feel much better.
There are some who argue that it is unethical to promote placebos to patients. But increasingly, many say it would be unethical not to give placebos a try in situations where patients are not getting relief from traditional means (and where it would not cause harm or replace a necessary treatment).
It’s clear that how doctors and nurses communicate their treatment can have profound effects on how patients experience the results of that treatment. Yet the conversation between doctors and patients is one of the least valued aspects of medical care. Insurance reimbursements for tests and medical procedures dwarf reimbursements for talking to patients or spending time thinking about what ails them. And the pharmaceutical industry, with its direct-to-consumer advertising, has promulgated the fallacy that every ailment must be met with a pill — brand name, of course.
As health care faces its latest overhaul, it’s crucial for the medical profession, as well as insurance companies and decision makers in government, to recognize the power of the doctor-patient conversation. It’s the most valuable diagnostic tool we have and can be remarkably effective as a treatment tool as well. Training for doctors and other medical professionals should emphasize communication skills with the same rigor that it does for other clinical skills.
Call conversation a placebo if you like, but if it helps without causing harm, then it’s legitimate medicine. Relieving suffering, after all, is what the Hippocratic oath is all about.
ACOG released new guidance advising providers to consider “low tech, high touch” approach to care for low-risk women. The Midwifery Model of Care as delivered in the birth center setting has studied this approach, and our data also supports the low-intervention approach as providing a SAFER model of care, avoiding the risk of unnecessary intervention. It is wonderful to see ACOG endorsing this evidence-based model, and also acknowledging that emotional support is an important factor in providing safe standard of maternal care. Bravo, ACOG!
From their press release:
“Practitioners always put the best interests of moms and babies at the forefront of all their medical decision-making, but in many cases those interests will be served with only limited intervention or use of technology,” said Committee Opinion author, Jeffrey L. Ecker, M.D., chief of the Obstetrics & Gynecology department at Massachusetts General Hospital. “These new recommendations offer providers an opportunity to reexamine the necessity of obstetric practices that may have uncertain benefit among low-risk women. When appropriate, providers are encouraged to consider using low-intervention approaches that have been associated with healthy outcomes and may increase a woman’s satisfaction with her birth experience.”
What constitutes “low-risk” will vary depending on a laboring woman’s condition and medical circumstances but generally involves a clinical scenario in which a woman presents at term in spontaneous labor and has had an uncomplicated course of prenatal care. For such women in the early stages of labor with reassuring maternal and fetal status, patients and providers may consider delayed hospital admission until approximately five to six centimeters dilated. Also, for women who are progressing normally and do not require internal fetal monitoring, it may not be necessary to rupture the amniotic sac. In the case where a woman at term experiences premature rupture of membranes, patients and providers may consider planning a short period of expectant management before undertaking labor induction if there are no maternal or fetal reasons to expedite delivery.
The recommendations also suggest that women benefit from continuous emotional support and the use of non-pharmacologic methods to manage pain. Support offered by trained labor coaches such as doulas has been associated with improved birth outcomes, including shortened labor and fewer operative deliveries. In addition to considering use of medications or epidural anesthesia to manage pain in labor, practitioners are encouraged to offer women coping techniques, such as massage, water immersion in the first stage of labor, or relaxation techniques. Recognizing that the complete absence and elimination of pain is not what all women value, use of a coping scale rather than pain scale is recommended to evaluate the multifactorial experience of labor.
Babymoon Inn is a full-scope midwifery practice and wellness center with locations in Phoenix and Tucson. Our team is committed to improving maternal outcomes and providing personalized, evidence-based care to all people.
Babymoon Inn is a full-scope midwifery practice and wellness center with locations in Phoenix and Tucson. Our team is committed to improving maternal outcomes and providing personalized, evidence-based care to all people.