Posted by My OB said WHAT?!?.
Feb
20
Posted by My OB said WHAT?!?.
“You Are Wiping To Hard When You Go To The Bathroom.”
“You are wiping to hard when you go to the bathroom.”- OB Resident to mother who started bleeding at 32 weeks of pregnancy. Turns out it was her cervix dilating and effacing, and she needed to be put on meds to stop preterm labor.
There are 24 comments to this post.
You would think that even the most junior doctor would know to use a speculum to examine the cervix and see what is happening……
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Jess Reply:
February 20th, 2010 at 5:51 pm (Quote)
Do OBs use speculums when doing prenatal cervical exams? That seems a bit overkill?
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Andy Reply:
February 22nd, 2010 at 6:45 am (Quote)
It is imortant to check for the source of bleeding. If a woman comes in complaining of bleeding ‘down there’, then you need to know where it is coming from. It could be excessive wiping (either vulval or rectal), it could be vaginal, or it could be cervical. If cervical, is it an ectropion or cervical erosion, or is it coming from the uterus via the cervix? The way to find out, if you have excluded external causes, is to use a speculum to check the cervix. If the blood is seen to be coming through the cervix, then further investigation is needed. We also use this when a woman comes in with query ruptured membranes. If a speculum shows fluid in the vagina, then we can confirm that the membranes are leaking. At the same time, you can visualise the cervix and see whether it is long and close or starting to open. Midwives and doctors take this route when assessing women who present with vaginal loss, though we don’t touch women under 36 weeks. If a woman’s waters have gone, the less you do with fingers and rubber gloves the better, since there is always the risk of introducing external infection, which is minimised (but never eliminated) by using a speculum. We don’t VE a woman whose waters have gone unless she is in established labour (which you can assess using eyes, ears and hands, NOT gloves and KY). If you do, then, according to our local protocol, we need to induce after 12 hours because we have possibly introduced bugs.
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Andy Reply:
February 22nd, 2010 at 6:50 am (Quote)
Of course, if a woman comes in saying that she felt a big pop, and water came flooding out in a scene from Titanic, then you can assume the waters have gone, and you don’t need to speculum at all. Likewise if she shows you soaking pads, or wet trousers. In those cases the gloves stay off, because it is safe to say she has ruptured her membranes without needing to put her through the embarrassment of a vaginal examination. Note to OB’s everywhere: ‘This is known as using clinical skills’.
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Sheva Reply:
February 22nd, 2010 at 7:59 am (Quote)
Why can’t they just use the Nitrazine paper? That way nothing has to be stuck inside her, just touch it to her and see what happens!
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Andy Reply:
February 22nd, 2010 at 8:27 am (Quote)
Not for bleeding. It is important to identify the source of bleeding, whether uterine or cervical. Nitrazine will tell you if liquor is there, but sometimes it is good to asses the cervix, especially if it is preterm. Of course, the less you do, the better. Which is why a woman who is term (ie 37 weeks onwards), who gives a clear history of SROM, needs no intervention at all if the baby is ok. We don’t use nitrazine much- I’ve only see it once. I can’t remember why, but there is some clinical issue. Women with hindwater leaks, for example, may only leak small amounts. In any case, as I said, it is only a small part of the overall clinical picture.
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Sheva Reply:
February 22nd, 2010 at 8:32 am (Quote)
I was referring to your mention of ruptured membranes. I realize that it can’t be used on bleeding.
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Andy Reply:
February 22nd, 2010 at 1:50 pm (Quote)
Sorry, I am being dim- just finished 5 nights in a row. Like I said, we don’t use nitrazine paper (it has a different name over here but I can’t remember it) because it only tells one part of the overall picture. Of course, if a woman says ‘don’t come near me with that,’ then the speculum stays out anyway, and we assess conservatively (i.e. wait and see).
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jespren Reply:
February 22nd, 2010 at 6:12 pm (Quote)
I’m not in the medical profession but I have been told by them that nitrazine paper is dubious at best because it reacts to normal vaginal secretions the same way it reacts to amniotic fluid, so, even if you try to first make sure everything is super ‘clean’, you can’t ever be sure what its reacting to.
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Nicholas Fogelson, MD Reply:
February 28th, 2010 at 3:44 pm (Quote)
Nitrazine alone is a very poor test for ruptured membranes – unless rupture is obvious, a speculum may be needed to confirm or deny rupture of membranes. Wiping a nitrazine paper on the perineum is not an accurate way to do it. Other things turn it positive, and it may not turn if the rupture isn’t large.
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Michelle Potter had this to say,
Feb 20, 2010 @ 5:53 pm (Quote)
How the hell do you wipe with TOILET PAPER hard enough to BLEED??
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KDB Reply:
February 20th, 2010 at 7:08 pm (Quote)
She obviously was using the cheap store brand. DUH! 
Seriously, this OB scares the crap outta me.
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MDL Reply:
February 20th, 2010 at 11:53 pm (Quote)
Actually, you CAN bleed very slightly from wiping – but that’s in post-menopausal women who are so deficient, they need a cream to help their skin be less crepe-like. In a normal, pregnant woman who is brimming over with estrogen, not a chance! And even in post-menopausal labia laceration due to toilet paper and menopause-induced thin skin, it’s a slight spot of pink-ish-red, not “bleeding” (I know, because it’s happened to me several times until my midwife, not the doctors, who I now see for my GYN needs helped me find a wonderful solution)- this guy’s a whackjob! That poor woman!
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Andy Reply:
February 22nd, 2010 at 7:46 am (Quote)
You are clearly not British! When I was in primary school, in the early 70′s, the standard toilet roll was ‘Izal Medicated’. This was a heavy duty gloss finished paper that didn’t so much wipe as smear around. This stuff could probably be used to polish diamonds, and could definitely remove skin, especially in the outside toilets that existed those days (aaaah.. the heady days of Empire!) And, you were only allowed one piece! Actually, Izal Medicated is still available from larger chemists,as is the even older Bronco, an even heavier duty paper (I use the term loosely- it is more like thick greaseproof baking paper. Probably from the same factory.) I imagine it is bought by older folk with a nostalgia for the days when rectal discomfort was seen as a badge of honour.
Seriously though, it is possible to bleed, vaginally and rectally from rough wiping. Piles will give an increased risk, as will the hormone changes of pregnancy and menopause. It tends to present as smearing on the paper reather than active fresh blood, which is not a good clinical sign.
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MDL Reply:
February 25th, 2010 at 8:58 pm (Quote)
OUCH! That ‘Izal Medicated’ paper sounds horrid. And only one piece? Wow – I think I’d rather splash water on my bits! (and no I am not British) – but I do love to learn our differences in culture and terminology… You might have laughed when I first learned of ‘spotted dick’ from a friend in Wales) Thanks for the info – I learned something today – and the day is not wasted! 
Blessings!
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The Deranged Housewife had this to say,
Feb 21, 2010 @ 5:44 am (Quote)
OK, some of these comments seriously make me want to blow coffee out my nose. LMAO!
The one time I dealt with a resident in labor, I could tell he didn’t really know his butt from a hole in the ground, which is sad. However, it gave me enough leverage to put him in his place. LOL
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right, because when I wipe I like to use a steak knife to really scrape the crud off… seriously?! Wiping too hard?!
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