Posted by My OB said WHAT?!?.
Jan
31
Posted by My OB said WHAT?!?.
“…That Isn’t A Cervix, It’s An Anus.”
“Oh! That isn’t a cervix, it’s an anus.” – OB announcing an undiagnosed breech to a mother in labor.
There are 26 comments to this post.
So is this OB announcing that he just gave the neonate a rectal exam?
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Sadly, I have seen this in action. I had a client go in to the hospital in very active labor. The nurse checked her and announced that she was less than 1 cm dilated and 35% effaced. There was NO WAY that was the case, due to her labor signs, but they kept her because her water had broken. An hour or so later, mama was feeling pushy, and the OB came in to see what was up. She did an exam and the baby’s bum was right there, ready to be born.
Unfortunately, this was a military hospital, and they did*not*do vaginal breeches under any circumstances, she was whisked off to surgery and the baby pushed up and out.
They never mentioned the fact that the nurse mistook the baby’s anus for a cervix…
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I would love to hear the OP’s story on this. Because, as appalling as everyone seems to think this is, it’s just the nature of OB. As a very experienced L&D nurse (of the crunchy, all natural persuasion!), a finger in a baby’s bum is a clear indication of a breech baby. Unless this is known ahead of time, sometimes a woman is diagnosed for the first time in labor at the hospital. And it’s often nurses that are responsible for the diagnosis. However, it does not happen very frequently at all, and even someone who’s been in L&D for years may never have had the chance to experience a breech on vaginal exam. If the nurse is astute to other findings (suspicious Leopold’s maneuvers, or just an sense that “something isn’t right” with the vaginal exam), she *might* detect it early enough to notify the MD or MW, maybe even pull out the U/S machine for confirmation.
The point I’m making here is that this happens. Even on a vaginal exam, a baby’s buttocks may feel firm like a head; fetal heart tones *may* be heard in the lower half of the abdomen; etc… if the membranes are intact, breech can be a difficult diagnosis. It happens often enough that a woman is admitted in labor and it isn’t until hours later that she’s diagnosed as breech when there’s now a rush for a cesarean delivery. (I’m not arguing in any way that I agree with c/s for breech!) And often this happens for the best of intentions: the OB trusts the RN’s exam of 1-2cm and doesn’t see the need to increase the likelihood of infection with a repeated vaginal exam for a few hours (so if she was really 4cm on admission, 3 hours later she could be 8cm for example when the OB does his/her first check and the breech is more obvious and readily diagnosed).
So, what I’m saying is that this happens. Doing a vaginal exam and finding *1 cm* is classic. It’s just fact. I would dare say that most OB nurses have had this experience 0-2 times in their careers. This just means that when an astute RN identifies this early, there is more of a (for lack of a better term) thrill of the diagnosis and sometimes seemingly inappropriate things are said. Even a younger doctor may have had this experience a few times. It’s not routine. So a doc saying, “this isn’t a cervix, it’s an anus” is actually a very accurate description of what’s going on. Most likely, the doc is not glorying in doing a rectal exam on a baby. He’s probably confirming suspicions to the RN who said to him on the phone, “I can’t really tell how far she is, it’s a weird exam.” Which it is- butt cheeks and an anus are VERY weird to feel if you are expecting to feel the firmness of the baby’s head.
Am I making sense? What I’m saying is that this happens and it’s not anyone’s desire to make light of the fact that they just palpated a laboring woman’s baby’s anus. That does not lessen the providers need for TACT and good bedside manner, however. Where this doc went wrong was in his/her description of findings. I agree with an above poster. A more simple, less horrifying way to explain this would have been, “What I am feeling is your baby’s bottom. That is why it was hard for Nancy nurse to get an accurate feel for how dilated you are. In my best estimation you are *6 cm* dilated, but your baby is breech. We need to discuss the plan of care at this time.” No need for mentioning the baby’s anus!! It’s implied to the nurse/doc that that’s what they’re feeling, but the parents didn’t need to know that. That is where I feel the mistake was made here. But please hear me when I say that though this doesn’t happen often, and when it does, it can be very surprising to the one who figures out a breech by a vaginal exam. And lets be honest, without ultrasound, most likely any provider would confirm suspicions of a breech presentation palpated abdominally with a vaginal exam!!! It’s not our intentions as nurses and doctors to sound inappropriate, and it’s certainly no excuse, but sometimes a surprising situation can lead to inappropriate comments that sound benign to us, but that can be hurtful to our patients. No excuses though!!!!
Let’s hope the OP can clear this up!!
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Cmat Reply:
January 31st, 2011 at 4:01 pm (Quote)
Makes sense to me. Could have chosen better words, but sometimes things take you by suprise! Frankly, its better that they said “anus” instead of “***hole.”
I guess what I’m saying is it could have been worse. It is kind of a wtf moment, but what can you do!
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Sheva Reply:
January 31st, 2011 at 4:12 pm (Quote)
Thank you for your clarity and sensitivity! Not a common combination in a medical person. How long have you been in L&D?
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Kathleen Reply:
January 31st, 2011 at 5:07 pm (Quote)
Thanks, I work hard to be an advocate for my patients and be the liason between patients and providers. It doesn’t always work though!!
I’ve been an L&D nurse for almost 10 years and a CNM for 7 years. I’m practicing as a nurse right now, so I see a lot. I’ve personally diagnosed a breech in labor, even when another nurse with as much experience missed it. I also *know* I missed one a few months ago; she was early in her labor and it’s easily mistaken. I don’t know who eventually figured it out, but I’m sure it was with no less surprise than any other breech discovery.
I know I’ve heard patients exclaim something like “I was in labor for x hours before they figured it out… how come they didn’t know sooner??” Well, it’s not always cut and dry.
Personally? I blame society. Something goes wrong, we sue. Malpractice insurance rates go up. Practices close. More patients are channeled through the same amount of hospital beds. Nurses are over worked and under-oriented to the normal or variations of normal. We rely more on the fetal monitor and ultrasounds than we do our Leopolds maneuvers. We can’t rely on our patient’s instincts because they have none. We have replaced healthy respect of the pregnant/laboring woman with fear: fear of pain, fear of the tiny percent that something will go wrong, fear of lawsuit…. we set ourselves up for let down. I do not fault any woman, certainly not the OP… but lets be real. If a well respected, loved, delivered all my families babies crunchy midwife said this, would we be having this discussion???? Why do we trust our care to people/docs that we don’t entirely trust?? We as women, as customers of health care need to make wise choices in our providers. There are some situations we cannot change, but the one’s we can- do it. Change! Be the patient you want to be. Find the provider that you want. It may not happen for everyone, good docs are hard to find. They’re not in demand! We need to make them in demand!!!
Wow, I’m going off on a tangent here… guess I should stop! No hard feelings here, I just have to speak up as a medical professional now and then to say that we’re not all bad and sometimes things we say get mistaken. As a *GOOD* nurse, I know I’ve seen things posted on this site that make me think twice. Have I ever said that?? Yes, I have… but I didn’t mean it that way.. did she take it that way?? Oh I’d feel horrible if she did… I don’t think she did, I think she knew I was trying to help….etc…….. us good ones are always second guessing ourselves…..
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Marissa Reply:
January 31st, 2011 at 7:09 pm (Quote)
So, feeling a little aha moment, would you say that unintentional rectal exams might be part of the danger in care providers who are unexperienced with breech births causing the star-gazer problem? I would imagine that suddenly feeling someone’s finger in my patoot would cause my moro reflex to engage, hardcore. I’ve been known to jump or kick when I get goosed. My husband doesn’t do that anymore.
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Erin Reply:
January 31st, 2011 at 7:41 pm (Quote)
Thank you for your response Kathleen. I believe I am the OP, if that means mother from this quote. You have made a lot of brilliant points. This moment was about 30hr into my labor, 7hr after arriving at the hospital, but only the first vaginal exam I had requested since being admited at 4cm nearly 100% effaced. I had been wanting a quiet natural birth and so had requested no extra vaginal exams until I asked, and when I arrived baby was still high up. I do believe it was an honest mistake as far as the excitement of discovery and don’t blame the staff in any way that it hadn’t been discovered sooner. I really like the detail that you added about this as it helps to clarify their side of view for me and any bit of closure and understanding in this matter is huge for me right now. Thank you!
I have also done a lot of research about breech birth since and have heard a midwife describing a woman’s cervix that appear to have two sizes (as if the outer “sleeve” was stretched more than the inner) and that it is common to feel that if the baby is breech. I appreciate your point of view as well as I now know it’s possible to miss it entirely even if you don’t have the two size scenario. For me, I was begining to feel “pushy”. Not that my body was taking over, but I wanted to push. I was starting to show signs of being in transition and so I requested a vaginal exam. Now I am not sure what happened here, if maybe the message got changed. I simply wanted a vaginal exam to know if I could start pushing. I believe my labor support told the nurse that I was feeling I needed to push. I was told to wait until my doctor arrived for the exam, She was woken up and a little over an hour later she examined me and told me I was 6cm dilated and my cervix was very hard. I have often wondered here if this was her feeling the baby’s bum or my cervix? Can the cervix be 100% effaced and then harden? I have also wondered if it was because of the delay and the fact that I was lightly pushing. Perhaps I caused my cervix to swell as it wasn’t fully dilated? I have heard it is common to feel a premature urge to push if the baby is breech, and me not knowing of the breech I am afraid I may have been part of the problem by doing so, even though I wasn’t straining very hard.
Either way, at this point the doctor seemed annoyed at me, which is probably why I have a problem with this quote. Yes it is true, if it was a beloved family doctor I probably would have laughed and appreciated her lightening the mood. As it was, I felt she was annoyed at being woken to deliver a baby, and finding out I was only 6cm. She proceeded to tell me I was too tired and my uterus wasn’t strong enough to have this baby and that I should let her break my waters. Despite my strong desire to use herbs and gravity if this case arose… I paniced, forgot, and let her break my water. There was a lot of meconium present and so the doctor told me she would perform another vaginal exam (I did not ask for this one) to which she replied “Oh! That isn’t a cervix, it’s an anus”.
I was wondering did she think telling a terrified woman who was dead set on a natural, vaginal delivery that her dreams may be crushed in the form of a joke is appropriate? Or did she actually mistake my child’s anus for a 6cm cervix?!? Maybe the butt crack??
Overall, your last comment – although you may have felt was ranting at the end lol – really hit home for me: about choosing practitioners that you trust. I knew I didn’t trust this doctor. She was the doctor that had seem me every appointment for the last month, and when she knew of my unconventional birth plans (like squatting to birth, refusing the automatic pitocin shot upon delivery, or delayed chord cutting) seemed to stop putting in quality care. Our last four appointments she quickly palpated me and confirmed head down and moved on to the next patient, jokingly mocking me that I seemed to know how this was all going. I understand that a breech presentation can be very difficult to diagnose, and I understand that it may be annoying to feel as though the mother is stepping on your territory as a professional, but what I was missing was the collaboration. I knew my style didn’t mesh with this doctor and I should have found someone else. I often wonder though if our lack of “chemistry” lead to less detail during prenatal exams, resulting in the miss of the breech.
I am also dissapointed in this doctor that at this point a cesarean was scheduled for me and only later was I informed by my doula that the hospital, and that doctor even, perform vaginal breeches. My doula said the doctor had said she didn’t recommend it for me. I was never asked which I would prefer and thought at that moment that if I had tried a water birth at home as I had considered that we would likely have both died. How misinformed I was.
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I love Kathleen’s point about trusting your care takers. There was no trust here, and so what was likely an innocent, surprised comment was taken as highly inapprorpiate. First, I will conceed that.
However that being said, there are several reasons why this is one perfect example of this one doctor’s level of inappropriateness.
Let’s leave aside the fact that this comment literally left me wondering if the OB had just stretched my child’s anus to 6cm. We can even leave aside the fact that this doctor had seen me every week for the last month, quickly palpated me (I say quickly as opposed to a much deeper, and longer, palpation which was offered by my doula prenatally), and confirmed head down.
I won’t leave aside the fact that this is the one doctor that told me I would have to include in my birth plan “exactly how long I wanted to bleed out before they could help me” if I wanted to refuse the routine shot of pitocin when the baby is crowning. I will include how she proceeded to tell me how my uterus wasn’t toned, I was too weak and exhausted, and that my contractions were pittering out: as if a female OB/GYN of her years (which were consideralbe) has never seen a woman have a plateau with contractions before hitting transition. I will definitely include how shortly after this statement she told me that if I hadn’t declined vaginal exams prenatally, that she would have known the baby was breech; so you couldn’t tell when you checked at 4cm, or at 6cm, but 4 weeks ago you would have been able to see past my 1cm dilation and the bag of waters… right, I forgot how you were magic. I will include how it was only after I was taken away to be preped for an “emergency” cesarean that this one particular doctor told my spouse that if I had my waters broken at midnight when I came in, there would have been less of a chance of me needing a cesarean. This was how I found out vaginal breech birth is possible, when days later my partner told me this. Not only do I doubt if that would have helped prevent the c-section, I find it outrageous to suggest that a healthy woman, with perfectly natural pregnancy and labor, breaks her waters immediately upon arrival, for no reason at all. And most importantly, if breech birth was a possibility, in that hospital and with that doctor (as I later learned it was) why was this never discussed with me. I allowed the baby’s heart to be monitored after my waters were broken and breech was confirmed, yet baby’s heart was strong. I was never told what the reason was the doctor recommended I didn’t deliver vaginally. At the time I didn’t believe it was possible; as silly as I now feel that statement is. The point of inappropriateness I was most hurt by was probably the fact that while lying alone (my partner had left to be with the baby), currently being stitched up and shaking so badly from nerves my arms are jumping up off the table slightly, and all I know so far is that there was a lot of meconium present when they broke the waters, and that I was pushing back three other c-sections to have my baby, the doctor leans over me and says the words, “are you really not going to let us work on your baby?”. Terrified I asked what she meant and she responded in regards to our discussion and my birth plan about Vitamin K drops and antibiotic eye drops. Now I know I should have stood my ground here after realizing that her Awfully!, no Horrificly! worded statement was only a scare tactic… however at that moment, it worked. I was broken. My heart was broken, and I told her I wasn’t sure about any of my birth plan any more. At that point she said the first thing to me reassuringly, “that’s good, after all you’re a mom now and have to make choices that aren’t just best for you”. She said it so nicely, yet was mocking that everything I believed in was simply a selfish, unreasonable, dangerous desire. And finally, the most invasive example of this particular doctor’s inappropriateness came after the baby’s birth when a urine catch was taped to my baby to be tested for marijuana. This particular doctor came and told me this the first night, after I had been left alone for the evening. She looked me in the eye and told me it was routine when I questioned why she was doing it. The next day I told my partner and he got quite upset and asked the nurse why it was done. The nurse told him it wasn’t standard, but had been requested by our OB. I guess my Crazy hippy anti-chord-cutting, squatting, drug free birth means I must be unfit to raise a child.
Since my surprise frank baby, I have done a lot of research about breech birth. Believe me when I say I appreciate how hard it can be to determine a breech presentation. I do honestly believe this was a fairly benign, near innocent slip of discovery. However it also tells of this OB’s carelessness to patient esteem, and complete casualness that I dare say may infact reflect the amount of care she provides! This was only one small example of the many! extremely inappropriate responses.
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road2vba2c Reply:
February 1st, 2011 at 4:58 am (Quote)
What a horrible woman. Don’t beat yourself up over this. So many things I did during my first birth that I look back and want to smack myself in the forehead. Mainly, accepting an unneccesary cesearean. I hope you’re able to have the birth you desire next time, without the condesending inappropriateness!
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… *hangs head*
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