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“You’re dilated to a 9, but I can stretch you to a 10…is that the cord?”  -OB speaking to a nurse as the baby’s cord prolapsed because of the ‘extra’ room he created by stretching the cervix.

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 March 23, 2010  Cervical exam, cervix, Cesarean, OB  Add comments

  30 Responses to “"You're Dilated To A 9, But I Can Stretch You To A 10…Is That The Cord?"”

  1. Please tell me the baby survived this act of medical malpractice.

  2. Oh, hell. Well, doc, better keep your hand up there, then!

  3. This happened to my mom–the stretching to a 10, not the prolapsed cord, thankfully.

  4. My midwife stretched me to ten, too, because I had a lip that I couldn’t get rid of, and I was tiring out. But she did it slowly, over a few contractions. I’m guessing there’s a difference between stretching from nine to ten and getting rid of a lip? And I’m also guessing there’s a difference in the way different practitioners do it?
    Anyone here know?

    • I’m thinking about this more and I’m also not picturing it. By the time the mom is at a 9, the baby’s head is pretty securely in the pelvis already, and the cord shouldn’t be down there. If the cord is alongside the baby’s skull at that point, it’s already being compressed and that wouldn’t be good for the baby either.

      • The baby wouldn’t still be up and floating at this point, right? Unless she wasn’t really 9 cms, in which case stretching her manually that much would be, among other things, hellishly painful.

        • We need the OP to come in and clarify what happened here.

        • Just on that–I dilated to a 10 with my baby still “up and floating”–she never descended (cesarean after an hour and a half of unsuccessful pushing). So that’s actually definitely possible.

          He should have left it alone.

        • Haven’t you ever seen a baby born in the caul? The amniotic sac can dilate the cervix just fine.

          Also the cord vessels are protected by Wharton’s jelly that has only two jobs: stop the vessels getting compressed, help clamping by cooling the vessels after birth

          • Yes, I caught a baby in the caul (my first catch).
            But I think the head is engaged against the cervix, even within the sac. I guess we need more info here.

  5. Theoretically, you should not have a cord prolapse, even with “stretching” from 9 cm to 10 cm manually. However, if there is an occult cord prolapse – basically where the loop of cord is next to the baby’s head and is not seen or felt, POSSIBLY the cord could come down below the baby’s head. I would imagine though that the pressure of the baby’s head on the cervix should be low enough to NOT allow the cord to slip through.

    Please, let us know how this birth turned out!

    • Is it possible she wasn’t dilated to 9 and he just told her that so she would allow the procedure?

      • Very possible. Also, very dangerous to try to stretch a cervix if it’s not close to 10 cm. I have reduced anterior lips with pushing (basically, holding the little sliver of cervix back over the head while mom pushes — with her permission, of course!!) Anything other than a lip, or 9cm if you will, is putting too much manual pressure on the cervix and can lacerate it.

      • Let me also further clarify: I only attempt to reduce an anterior lip if the mom has a strong urge to push, is already pushing, and is agreeable to my helping her. If it hurts her, I stop immediately.

  6. breech baby maybe?

  7. Sorry, I don’t buy this one. I’d love to hear the OP’s explanation of how this happened but right now I don’t buy it.

  8. (Copied from my comment on Facebook)

    This sounds like a standard part of a thorough cervical exam to me. The condition of the cervix (stretchy, loose, tight, etc) is part of what you are checking. If she consented to being checked, she consented to being checked well… our fingers aren’t up there to give us jollies, we’re getting information! I think my clients will vouch that I’m a pretty gentle midwife who gets consent and respects the revocation thereof; there’s nothing wrong with this quote with the information given. The concept that the cord prolapse was caused by gently stretching the cervix (or even roughly stretching the cervix) is absurd. If a prolapsed cord was discovered in the process of a cervical exam, it was a very timely discovery!

    • This is not a standard “thorough cervical exam”! Checking dilation is what women expect when a provider asks to examine them. Pushing the cervix from a 9 to a 10, or even from a 9.5 to 10 is an entirely different thing from a standard cervical exam. It is not something the woman expects to happen, nor does she consent to it if she consents to a standard vaginal exam. With a standard exam, the woman is quickly checked in between contractions and it is uncomfortable but relatively painless. This is what women come to expect during an exam. If they consent to an exam, this is what they are consenting to. Manually dilating the cervix is an entirely different procedure. If the woman is not consulted or given the opportunity to consent, she is generally checked, but then the provider stays inside during a contraction (which can be extremely painful and frightening in itself), the provider then pushes the cervix open further than it is already, which can be horrifically painful. This [unconsented] act can feel like a violation. It should never be done without consent because there is a great risk of trauma being caused to the woman.

      Women have a right to be informed of procedures before they happen, be told the risks, benefits and alternatives of that procedure, and then either choose or refuse to have that procedure done. Downplaying or minimizing a procedure does not give a provider the right to perform it without the woman’s consent.

      • I’m sorry, but you are misinformed. Cervical dilation is only one of many things a provider ought to be checking for as part of a standard cervical exam. Wouldn’t you consider it negligent for a provider to check a woman for dilation ONLY? What about effacement, station, presenting part? Can you imagine a provider saying, “Oh, I was only checking for dilation, you can’t expect me to have realized the baby was breech!” How many women WISH (or would wish, had they any idea) their provider had checked for attitude or asynclitism while they were doing an exam, instead of only caring about dilation. Other things you check for: condition of the baby’s head, condition of the bag of waters, cervical adhesions… there’s lots of things besides dilation! Anyone who thinks otherwise learned obstetrics by watching movies.

        I doubt you’ve ever checked a cervix, based on what you’re saying. Stretching a stretchy cervix is so different from “manually dilating” someone that if you really knew what you were talking about you’d never confuse the two. Checking for dilation (and everything else you check for, routinely, every time you check a cervix) will OFTEN lead to a report such as “6, stretchy to 7.” Gently determining how stretchy she is does not cause undue pain such as you are describing.

        I’m trying to think of an analogy but I’m coming up short. This isn’t close to perfect but I’ll try it anyway: someone says, “Reach into my purse and grab my cell phone.” While your hand is in the purse, you notice a bottle of water is leaking into her purse, so you pull the bottle of water out of the purse. This is the appropriate course of action. If you had noticed the leaking water and NOT pulled the bottle out, she would have been rightfully annoyed with you. You can’t claim, “Well, I was only told to pull out the cell phone, not the bottle of water” without sounding like a jackass. SO, to the point that this analogy works, he reached in and in the normal course of an exam noticed something unexpected that was actually very important information. Now the peanut gallery is claiming he should be sued? Mmm K.

        • Your ad hominem attack is not going to win you any arguments with me. That tactic is a clear logical fallacy.

          In the quote above the OB said he was going to stretch her from a 9 to a 10. Doing a vaginal exam, which an include all the other things you described, does not include stretching a cervix from a 9 to a 10. This is not what women expect when they consent to a vaginal exam. The quote does not include the information that the cervix was stretchy, but even if we assume it was, does that give the provider the right to stretch it without consent? By that logic, the provider could also break a bag of water without consent if they happen to feel it there during an exam.

          Performing any procedure should only be done with informed consent. If you are manipulating a cervix, that is not the same as checking and assessing – and I can assure you feels quite a bit different to the woman. It is unethical and manipulative to gain access to enter a woman for an “exam” and while you are in there deciding to stretch the cervix when she did not consent to that being done. It would also not be appropriate to break the water, or strip the membranes during a prenatal. All of those things would be unexpected and not something normally included in a standard exam. If you wish, for some reason to speed up the normal course of her labor and stretch her cervix open further than it currently is, then why not simply get her consent to do so? Let her choose if she wants her labor sped up or not. Not all women do, and many women find any manipulation to their cervix to be extremely painful. Even normal vaginal exams can be very painful for some women, so staying in longer than was consented for and stretching the cervix is going to be intolerable for these women.

        • Leigh, no one said he should be sued. My comment was the first and I called it an act of medical malpractice, but then further down the page I recanted because it doesn’t make sense that stretching the cervix would have prolapsed the cord unless there’s some information we’re just not getting.

          I do know someone whose baby nearly died because the OB ruptured her membranes while the baby was still floating; that’s what I was reacting to, not the post, and I was wrong.

          • Jennifer, we are talking about two different things. Your definition of “stretching” and what I’m talking about are worlds apart. The quote doesn’t give enough information to determine which definition of “stretching” was being utilized here, but I really don’t see any reason to assume the worst. With the limited information available from the quote, there is no reason to suppose the practitioner did anything wrong. It sounds like something that could happen to the most gentle and respectful care professional in the world.

            Jane, you are correct that no one on this thread said that he should be sued. But people were saying that on Facebook, where I originally posted, and I carried that over. I can see how this story (which, barring further explanation, I feel compelled to declare “bogus”) would remind you of a prolapse due to artificially ruptured membranes, which is indeed possible malpractice.

          • ps. How do you determine whether or not something is stretchy? There’s only one way!

          • Why do you have to determine that? If a woman is dilated to a 9 and a provider tells her he can stretch her a 10, he is obviously manipulating the cervix. There is simply no reason to manipulate the cervix unless there is some kind of emergency going on, in which case the mother should still be allowed to consent to the procedure. A vaginal exam carries the implication of “checking” not “doing”. When you are switching from observing, checking and gathering information, to doing, stretching, or performing a procedure, that is a different thing altogether and requires it’s own consent. If a provider checks a woman and she is dilated to 9, there is no reason to push her cervix to a 10, stretchy or not stretchy, this is an intervention and one she should be fully able to consent to.

          • Well, you don’t “have to” determine whether a cervix is stretchy or not any more than you “have to” do a cervical exam at all. But, as long as you are doing an exam, condition of the cervix is one piece of useful information that you ought to be gathering. In the case of noting that someone is stretchy to complete, it may mean the difference between her being able to push now without swelling her cervix, and her needing to blow through her contractions for a while longer before that is possible. (This is all debatable… some midwives will say that an urge to push should ALWAYS be indulged, some midwives will say that pushing on a thin, tight cervix can cause severe swelling that can lead to a c-section… that is a debate for a different forum. My preference is to share my clinical findings with the client and discuss her options.) It may mean the difference between determining that progress has been made, or no progress has been made. It may assist the care provider in suggesting different positions, knowing how imminent birth is, etc. We don’t know exactly, because we aren’t assisting in the management of this labor.

            It isn’t an ad hominem attack for me to say that it is fairly obvious from your comments that you have never (or seldom) checked a cervix. I don’t know you, and I’m not attacking your person. I’m sure you’re a very nice person, a person of conviction, an educated person. You also may be a person who was traumatized by a care provider… I don’t know. But you are making a lot of negative assumptions about this scenario that aren’t borne out by the limited information we are given. AND I maintain that condition of the cervix, along with dilation, station, effacement, presenting part, and many other markers, are all part of a standard cervical exam. If you want to be checked, it is assumed that you want all the information that might be useful in managing your labor to be gathered. If you don’t want the information, you should not consent to the exam.

            I realize that you think that determining whether something is stretchy crosses the line into “procedure” but I completely disagree. Stripping membranes, breaking water, rubbing out adhesions, manual dilation… those are procedures that should rightly be consented to, not done as a matter of course. Feeling whether the cervix is a tight 8 or stretchy to 9? Part of a normal exam. When you stretch your fingers to determine the dilation, with minimal pressure you will start to notice whether you’ve got stretch. If a cervix is very thin and tight, you aren’t even going to try to stretch that. If you reach in and you’ve got the neck of a turtleneck sweater, you’ll want to know if it stretches wide open or not. The possibilities are endless.

          • If there is some issue as to why a woman is being checked for dilation – such as she is pushing and the provider feels it is necessary to see if she is complete or not, before she consents to this exam it would be reasonable to ask her if she would like her cervix stretched to complete if it is stretchy and she would like to push or has concerns about pushing on a not quite complete stretchy 9 or 9.5 instead of a 10. If she is examined under the understanding that the provider is simply checking so see if she is complete, and then the provider pushes her to complete without her knowledge or consent, I strongly feel that this is a separate procedure that she should have been able to consent to. To the provider, a stretchy cervix may feel ripe for the stretching, but to a woman undergoing this procedure, it may be incredibly painful. There is no reason to do it unless the woman specifically requests it, so why risk potentially traumatizing her over an unnecessary procedure?

            In the quote above, no conversation of consent is included, no information about whether the cervix is stretchy or not is included. If the woman was upset enough to post this comment, I think we can conclude that the woman was upset that the procedure was done in this way – presumably without consent.

            As for the ad hominem stuff (which means the person tries to invalidate the other persons argument by making personal jabs at that person instead of sticking to the facts of the argument):

            “Anyone who thinks otherwise learned obstetrics by watching movies.”

            “I doubt you’ve ever checked a cervix, based on what you’re saying.”

            “Now the peanut gallery is claiming he should be sued? Mmm K.”

            All of the above was off topic to the argument and only included to make me personally look as if I had no right to question your perspective.

          • He didn’t say “I’m stretching you to a 10″ he said “I can stretch you to a 10.” Noting that you are able to stretch a cervix out of the way and actually doing it are two different things. The difference is subtle, but there is a difference. For instance, you may be able to reduce the cervix but as soon as you move your hand it comes right back unless you’re doing some pretty agressive manipulation. Like Leigh said, it’s the difference between the information gathering that’s a normal part of a vaginal exam and actually attempting to reduce the cervix.

            That said, we can’t really say what happened here, because we weren’t there.

  9. Not sure about the prolapsed cord, but as far as I’m aware the exam is normal practice here in the UK, and no they don’t really ask your permission…if you are pregnant and in the hospital, then they expect to be able to do what ever examination or procedure they deem necessary. In my experience (I’m in my 10th pregnancy) the only ‘consent’ they tend to ask for is C-section and med students, and even then they tend to inform you to sign rather than ask you!

  10. Keep your ever livin fingers OUT OF THE WOMAN!!! If you have to stick your hand up someone to figure out how dilated she is, you shouldn’t be a midwife OR an ob!!! Ugh, I am horrified by the whole conversation going on here!!!

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