Last week we looked at the importance of birth preferences and how they can help to organise your thoughts about labour and birth, and to identify what’s important to you. While having written birth preferences to share with your support team on the day is really important, they will only be useful to you if you have carefully considered each item, understand why you have put it there in the first place, and if it is important to you that your caregivers are aware of this preference. Copying someone else’s birth plan – from a friend or the Internet – might seem like a great idea when there’s a ready-made one for you to use, but your birth preferences should be unique to you by reflecting your personal informed choices.
Over the next few weeks, we’ll cover a selection of preferences you might like to consider and include, and today I thought we’d start with a closer look at preferences around vaginal examinations.
Vaginal examinations or internal examinations are performed during labour to establish how your labour is progressing. You might also hear people refer to them as a VEs or “internals”. Your midwife or doctor will be able to inform you if your cervix is dilating and how many centimetres dilated it is. Your cervix is considered fully dilated at 10cm and it is at this stage that your baby starts making its way down the birth canal.
When you initally arrive at the hospital, your midwife will ask to perform an admissions vaginal examination to help decide your care pathway from that point onwards. If your cervix is less than 3cm dilated, your midwife might suggest that you go home and return when your labour has further progressed. Alternatively she might suggest that you are admitted to a pre-labour ward. If you are in established labour (3cm or more dilated), she will most likely send you directly to a delivery suite where you will remain until after your baby arrives.
Once you have been admitted to either the pre-labour ward or to a delivery suite, it’s worth evaluating the merits of further vaginal examinations. Some maternity units have a policy that they like to perform vaginal examinations at two hour intervals after that first admissions VE. Often this is offered as part of a care package called the Active Management of Labour however best international practice recommends that VEs should only be carried out either at four hourly intervals, where there is a concern about progress, or when the labouring woman requests them. The NICE Guidelines from the UK are a good place to start when researching information on evidence-based care.
There are a number of reasons for keeping VEs to a minimum. Reducing the risk of infection is one, particularly if your waters have already released. Any internal examination introduces something foreign to the area – be it a caregiver’s gloved hand or a medical tool/instrument – so minimising this also reduces the chances of an infection.
A second reason is that the bag of waters around your baby may accidentally release. We will revisit artificial rupture of membranes (ARM) – or breaking your waters – in a few weeks time but this might be something you’d prefer to avoid, and not having a VE is the only way to prevent this happening.
Another important reason is your own comfort. It is usually necessary to lie down when a VE is performed and this can be quite difficult and uncomfortable when your labour is quite far along. If you have been active during your labour or if you have been using your GentleBirth techniques, an unnecessary examination may break your concentration or upset the focus you were enjoying to manage your labour. Experienced midwives can usually tell from the behaviour and movement of the labouring woman herself how far along her labour is.
So what kind of preferences would you include on your birth plan when it comes to vaginal exams? Some women like to include a line that says:
“I would like to have a vaginal examination on admission and then at four hourly intervals, in line with best international practice”
Or drop the last part altogether and just say:
“I would like to have a vaginal examination on admission and then at four hourly intervals”
Others like to say:
“I would like to have a vaginal examination on admission and then only at my request after that, unless there is a concern for my baby”
“I would like to keep vaginal examinations to a minimum and only at my request”
Some women are happy to be guided by their healthcare provider on VEs, in which case you might not include any preference.
Whatever your personal preference is, be clear in your mind as to why that is your choice. Remember too that vaginal examinations can only be performed with your permission so you are more than within your rights to refuse an examination at any stage if you’re not comfortable with it. Take the time during your pregnancy to read the evidence around the benefits and risks of vaginal exams to help inform your decision, like the NICE guidelines mentioned above. This Cochrane Review is also helpful.
Next week, we’ll look at preferences around positions in labour and how they are relevant to you.
© Sylda Dwyer, AlphaBirth 2014. Unauthorised use and/or duplication of this material without express and written permission from the owner is strictly prohibited.