Jan 152013
 

“We have to check you, we have to know you’re progressing.” - OB to 3rd time mother when the mother stated her wishes to not have routine cervical checks during labor.

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 January 15, 2013  Cervical exam, labor, OB  Add comments

  54 Responses to ““We Have To Check You, We Have To Know You’re Progressing.””

  1. “You will ask my permission each and every time and if I say no you will drop it. My body my choice. If you can’t respect that I can’t work with you.” Then you stare at them like you are their Kindergarten teacher. Practise saying this in the mirror while wearing a paper gown.

  2. So mach zich heimish*, as we say, and you’ll hear her labor song change. That will be a clear sign that labor is progressing. No need to stick your fingers up where you’re not welcome.
    *make yourself at home – an expression that means, among other things, to settle in for the long haul

  3. how about you listen to how she’s vocalizing, pay attention to how she’s moving (or not), see how hard her belly feels, notice if she’s in the groove or still chatty and basically just treat the patient and not the cervix?

    • “Treat the patient and not the cervix.” YES. I would go further and say, “Treat the client and not the cervix.” Nearly all people in labor in a hospital are there because they need a spotter. They are not sick, they are not injured, and they are not lumps of meat out of which the baby must be extracted. They are having the babies; the OB is an awkward fill-in for a midwife. Treat the client, not the body part.

      • Why do you say the OB is an awkward fill in for a midwife?

        • I can’t speak for Jenny, but i would say this because imo a good ob isn’t the one good at what they were trained for (surgery), but the one who is good at watchful waiting. Midwives are trained in birth as a normal function, rather than as a pathology.

        • The medical model is trained to be proactive, whereas the midwifery model is trained to be responsive.

          The base assumption of obstetrics is that the process is assumed to be going wrong unless guided to go right, whereas the base assumption of midwifery is that the process is assumed to be going right in the absence of evidence that it’s going wrong.

          As a result, an OB deprived of constant information that reassures her/him of the process feels out of control because s/he needs the data to say “Everything is normal.” The midwife examines the data for moments it says “Everything is not normal.” The mindset is “interventions for normal labor to keep it normal” versus “interventions only for abnormal labor and only when necessary.”

          I assume people self-select into whichever mindset feels more comfortable to them.

          • **The mindset is “interventions for normal labor to keep it normal” versus “interventions only for abnormal labor and only when necessary.”**

            This is probably the best explanation I’ve ever heard of the difference between the models. And sadly, in the effort to “keep it normal” they too often end up CAUSING different kinds of abnormal results that they then have to “save” women and babies from. You’d think they would have caught onto this by now…I know, wishful thinking again.

          • And no wonder OBs are convinced birth is so “dangerous”…they keep MAKING it that way.

          • So you believe that an OB is fundamentally for a different job then a midwife, perhaps that they should all be MFM or something of the like.

          • Personally I think that there should be midwives everywhere, that all women should assume that they are going to see a midwife in pregnancy and labor and not an OB–because the OB’s original job description was obstetrics, not attending normal labor and birth. They should only meet the OB if the midwife refers them to an OB for trouble in pregnancy or if they encounter an obstruction to normal labor. I understand that this is the norm in other countries.

            If midwives can’t get their old field back, I would prefer as a second option the GP making house calls with his/her little black bag–and an ambulance on speed dial.

            Basically, the problem is that OBs are trained to assume that there is trouble. This is a problem because if there isn’t trouble–and there usually isn’t–an OB’s attempts to forestall the imagined trouble can actually cause iatrogenic complications. There is also the lingering mindset from the days of twilight sleep that the woman is the helpless, inactive patient from whom the infant must be extracted as speedily as possible, which leads to problems like continual cervical checks to assess progress in labor instead of observing what the woman does and asking what she feels.

          • It’s an interesting idea, not sure how practical. The main issue I see is the fact real complications do come up and someone needs to have the skills to handle those very real problems, and its hard to identify who is going to have those issues before labor starts.

            Not everyone can live 10 minutes from a hospital, and even if you do 10 minutes from a hospital is 30-45 from an OR.

          • Other countries do use a model of care in which midwives are the gatekeepers who are on the alert for complications, and on finding a complication, then refer to an obstetrician.

            Similarly, in labor you still have the same model of care only with an ambulance/flying squad on alert during labor in case the midwife makes the decision to transfer to a hospital.

            30 minutes from an OR can happen even in a hospital with an OR, unfortunately. If the obstetrician is at home in bed when your complication happens, the nurses need to page the OB, who needs to drive to the hospital and then get ready for surgery. If the hospital knows a transfer is coming in and will require surgery, it’s entirely possible she’ll still arrive at the hospital before the surgeon is ready.

            The real reason this model of care won’t take hold in the US is that we have too many obstetricians to limit them to high-risk cases where they’ll do the most good. Because these obstetricians want to earn a living, they will never willingly step back and say, “We would prefer low-risk women see low-intervention practitioners until such time as our high-intervention style is appropriate to the high-risk patient.”

          • That last statement is just not true. More doctors then ever before are getting out of the baby delivering business (it only takes looking at the recent John Hopkins lawsuit to see why). One of the reasons why we are having this new issue of there not being a doctor at the hospital when a women delivers is that there simply aren’t enough OB’s for them to do that if they also want to sleep and see their families every once in a while. In some areas women are traveling very long distances to find an OB who is free enough to take on a new patient.

          • Goldilocks, my last baby was delivered by homebirth midwives at home because the OB/CNM practice I’d used the previous three times (in hospital) decided to revoke the midwives’ hospital privileges. They admitted to the newspaper ths was because the midwives were getting too many deliveries and the OBs were not getting enough.

            I loved those midwives, but I wasn’t going to have prenatal care with them only to have the OB deliver me because the OB needed more births. If what you’re saying is true, the OBs wouldn’t have felt the need to revoke the hospital privileges of the midwives in their own practice.

          • That is a very regional phenomenon then, because stats show that less students are going into OB and more doctors are getting out.

          • Maybe in the end it will all even out, then, and the OBs will spread out to cover the territory needed and women will be able to receive care under insurance at a level appropriate to their personal risk level and comfort zone.

          • Goldilocks, there are twelve (I just confirmed this with a nurse in the labor wing) OBs on call at my local hospital, serving a population of fewer than 20,000 people, including people who have an option to go to the local military hospital instead. People don’t come to our borough (=county) to have their babies because we are a remote region without road access.

            Meanwhile, although I was able to have a midwife for all of my labors, there is currently no midwife in my borough. Regulations set by a committee of physicians were changed to require all midwives to take certain continuing ed classes available only in one city in the state, all transportation costs to be paid by the midwife. Midwives also have to attend a certain number of births per year, transportation costs to those clients to be paid by them. These regulations restrict midwives to the urbanized region of the state with occasional visits to towns like mine if they are contacted by people who can pay their airfare and lodging on top of their usual fees.

            I don’t live near Jane.

          • Couldn’t reply to the comment i wanted to reply to… but in my area the local hopsital discontinued their midwife program, which pulled 2 midwives out of practice, and a year later another local hospital closed, forcing an entire county of patients to descend on 5 OBs who were fie with just the ONE county of patients plus a few higher risk ones that were reffered to them, and the hospital shut down their NICU as well, so now all pre 37 week labors are transported 90 miles away because the OBs are overworked and have no NICU support, and they could really use those midwives to help share the load so they COULD sleep and see their families sometimes.

            especially since one of the OBs has a list of complaints filed agains thim 2 miles long, and the midwives hadn’t had any issues whatsoever with dissatisfied patients or malpractice.

          • Hi everyone,
            Organized medicine does not have to win the battle to bring midwifery back as the norm, as it is in many many countries that have much better maternity outcomes than the US. I work for the Big Push for Midwives Campaign, which is working with state-level consumer groups and midwives to help make midwifery legal in every U.S. state (we are up to 27 now). Some of our allies are working to obtain Medicaid and insurance and managed care coverage for midwives and home birth and birthing centers. The secret weapon to push back at organized medicine and the OB/GYN groups when they try to dominate maternity care is organized consumers. Each and every one of you can be part of a movement to make midwifery an option for every woman who wants one — in hospitals, at home, or in birth centers. Docs may have the money and the lobbyists, but there is nothing quite so compelling to a legislator than a thousand emails or phone calls from his constituents. Women don’t have to take birth lying down, as we say, but can take back control of their own maternity care though political as well as individual action.

          • My ob clinic currently has two nurse midwives who see all General ob and pregnancy clients. The ob steps in for surgeries and consultations on high risk patients.

            I’m having twins and my midwife is still my primary go to person, the ob will be involved in case of emergency but as long as things continue to go well he’ll just be there for consults and and extra pair of hands.

            I love the care I’m getting and have loved the way my midwife acknowledges that my pregnancy is higher risk but not something to be afraid of.

  4. When you see the top of my baby’s head, you’ll know I’m almost done.

  5. “So you’re saying these cervical checks are for your benefit and not mine? You’ll have to find some other way to satisfy your intellectual curiosity.”

    • Also:
      So, you’re saying you don’t believe me when I say I’m progressing, and only believe it if you feel it? Hm, someone has trust issues. Or god-complex issues. Or both.

      • I suspect some doctors have mixed up cause and effect, and that rather than measuring progress, they’ve begun to believe hourly cervical checks causes progress.

        This makes sense because in their minds, a woman is at a 4 until they do another check, and then she’s at a 6. It’s the information provided by the check that caused their definition of her state of labor to change, and after you do enough of these at three o’clock in the morning, I bet they all sort of blur until mentally, it really is the check that’s causing the progression of labor.

  6. It amazes me how people who call themselves medical professionals…experts in all things medical…have yet to grasp the simple concept of how germs cause infections. And yet, they’re the first to freak out about you getting an infection after your water breaks. You keep sticking a non-sterile object (your gloved fingers) up inside an otherwise sterile environment and eventually you’ll stick enough bacteria/germs in there to cause an infection. There you go, simple lesson for simple minds. Also, I couldn’t agree with you all more. All medical providers need to ask first for permission to touch you, and when refused, drop it. Case closed and move on.

    • I agree with you 100%. I wish… Somehow they think the hospital confers sterile conditions on all who enter. Which is ridiculous, because statistics say somewhere in the vicinity of (iirc) 700,000 people DIE per YEAR form hospital-acquired infections.

      • OMG, I KNOW! Amazing how that happens. And scary. I’m getting my hips replaced sometime this year (undiagnosed hip dysplasia led to years of pain and now bone-on-bone deformed hips at 40), and it terrifies me to think about those statistics when infection is the worst thing that can happen to you with these surgeries. And serious infections are a lifelong worry after that, too. Once the hips are done, though, if I’m lucky enough to have kids, I’m doing it at home with a midwife, come hell or high water!

  7. *sigh* I wish I wasn’t even in this situation. I have had 2 babies perfectly naturally, vaginally, in a birth center. I want to have this one at home. However, I have been having severe abdominal pain that has yet to be diagnosed, but I’ve needed treatment for in the form of narcotics. I have been trying chinese medicine, yoga, etc. I’ve asked for referrals to a pain management specialist to get alternative relief (such as a p-stim). Nothing. So, because of the risks of the meds, we have decided we may need to be near a NICU when bub arrives.
    At my last appointment, we were going over any thoughts/questions. I reminded her of my education (I am a doula, studying to be a midwife) and my previous experience. I feel comfortable in asking for a VE if I am doubting myself, but I am also very in tune with where my baby is- my last birth I told the MW exactly how many pushes I had left (2). I informed this OB that I will not consent to any VEs beyond the initial one (which I’m still not comfortable with, but ‘understand’ to some degree) unless I feel it is necessary. This was a fun visit. I’m still hoping for a resolution of this pain so I can have my home birth and not deal with this mess.

    • I’m so sorry for the pain you’re going through. :-(

      Regardless, the hospital doesn’t have a right to perform cervical exams on you. If you refuse, they have to abide by your decision. You may want to bring additional labor support with you if they’re going to fight you about this.

      Good luck, and I hope the pain resolves.

    • Oy… Bring a doula to help you stand up to the pressure. No pun intended.
      Also, I hope your abdominal pain is resolved. I had pain so bad this pregnancy (upper left quadrant, near my stomach and spleen) that I would sometimes curl up on the floor and cry. I still have it occasionally, but not nearly as strong. I suspected ulcers. Eating raw green cabbage helped some.

  8. This is why I loved my SILs dr, he only checked her onve every 6 or so hours unless SHE asked or felt pressure to push.

    • and she was in labor for 48+ hours being induced

    • How often do most docs/nurses/hospital professionals check women? Curious, because I’m having a HB and declining all checks. I guess I didn’t think they typically did it more than every few hours or so in the hospital, but I guess they do?

      • I’m pretty sure I was checked every hour with my first. It was definitely more than the every 2-4 hours the doctor said it would be when discussing my birth plan.

        • Wow… Huh. I guess I was aware of that years ago, before I had decided on homebirth, but now I must live in a bubble, because anything more frequent than every 4-6 hours sounds super-excessive to my ears.

          I just got back from a MW appointment and wanted to see what they usually do (I vaguely recalled that they didn’t do many cervical exams in labor, but wasn’t 100% sure of the “usual” procedure). My MW said they basically never do checks (and confirmed why– they’re not that helpful, can be harmful) except mayyybe if there’s some significant concern, or maybe if your labor pattern hasn’t changed for a reeeeeeeallly long time, they might want to see if you’re not dilating, or if you don’t “seem” like you are, but you actually are. Etc. And she reiterated that even then, you can decline (though if the situation were dire, I’m sure you/I/one wouldn’t want to). It was nice to confirm that I shouldn’t even really have to “decline” anything, because there’s a good chance no exams will even be “offered.”

          • Yep, that is why I had #2 at home just last month. The midwives never bothered with my vagina once in my pregnancy or labor until there was a baby coming out of it. Somehow we all still managed to know said baby was coming!

          • When I was preggo still I asked to be checked at 41+6. It was my only check since I didn’t call in time for the midwife to get there. She did have a student there as she was a teacher/mentor and she did ask if I felt comfortable letting the student do the cervical exam as well. I was fine with that. It was interesting and it struck me when we chatted after, how little experience (in VE’s)they get as a student midwife there, because they do them so rarely. I had the same student follow me through all my appointments, and I had 1 check, and she was the first one to arrive after the birth, but everything was already done by then!

        • first birth? at least 7 checks while in labor, plus 2 at appointments beforehand, one when i arrived at the hospital and they told me i wasnt in labor, one in the morning because they kept me all night, i had dilated 2 more CM, but was totally not IN labor…..

          2nd birth, 1 at a prenatal appointment, 1 upon arrival, 1 when i asked them to break my water, 1 when i was ready to push but i was in the tub trying to ride it out and was confused by wanting to push because i didnt think i was ready.

          so, it got better, but 4 is still a bit much. considering i was in the hospital for 5 hrs before he was born…

      • I was checked every hour with my first baby and only hospital birth. This was before I knew better.

      • My last delivery, they did a VE after every single contraction. Even though I yelled and fought that I didn’t want them to touch me. They also forced me to change positions every contraction too… even though I was holding the bed for dear life and begging them not to move me.

  9. Well SURE you can check me!
    When I’m pushing.

  10. I suppose my response would be “how soon do you need to know i am progressing?” i mean, you pretty much know my starting point is no less than zero, and my goal is somewhere around ten. If the doctor brings out the one cm per hour rule at any time i would be sure to hold them to no less than ten hours before the first exam. seems fair to me.

  11. I think that cervical checks are perhaps one of the most distracting and disturbing of normal birth Of all of the interventions. I’ve had two births and no cervical exams during labor and that’s exactly how i wanted it. I’m a doula also and I’ve seen the negative psychological impact that a disappointing exam can have on everyone

  12. Where I live, you need to contact your midwife before 5 weeks, or you probably won’t get one. They fill up quickly. No one seems to have trouble finding an OB. I don’t live anywhere near Jane, either. And we have the same problem of no midwives at all in the rural areas.

    That is a very regional phenomenon then, because stats show that less students are going into OB and more doctors are getting out.

    That is a very regional phenomenon then, because stats show that less students are going into OB and more doctors are getting out.

  13. Jane is wondering how everyone knows where she lives. :-D

  14. I agree that CEs can be hard on the mom, but SOMEtimes they are necessary. I wish I had known enough to tell my midwife that I didn’t want her to do a CE with my first, but it saved me a lot of pain with my third. I was laying on only one side, and my cervix only dilated on that side. The other side was only a 6. She did a CE and told me I needed to lay on the other side for a few contractions and that helped. The other side dilated. I had major hip problems (my legs were two inches different in length from them) with that pregnancy and it really hurt to labor on my other side, but it was what we needed.

    HOWEVER… Every hour… every two hours… in fact, any clock-based schedule is ridiculous. Treat based on the symptoms of the individual patient. Otherwise it is like the doctor sending you home with suggestions for flu remedies and three weeks later, your broken leg is still broken. Just because MOST people have come in this week with the flu doesn’t mean that ALL people who come in this week have the flu.

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