Vaginal Exams: Pregnancy & Labor

Are vaginal exams (also called pelvic exams, or cervical checks) necessary during pregnancy and labor? They can certainly be helpful at specific times, such as for being admitted to the hospital or birthing center when you're in labor, if you've gone past your due date, if an induction is needed, if there is a concern about labor progress, or perhaps a question of the baby's position during labor. What about checks during pregnancy, or during labor - when everything seems to be progressing normally, and the mother is fine and the baby is fine? This is your choice to make, based on the pros and cons, your care provider's recommendation, and your feelings, opinions, and intuition. More information on vaginal exams is below, from a few different sources. Read, be informed, and decide for yourself - based on you, not anyone else.

Evidence on Cervical Checks at the End of Pregnancy

Pelvic Exams Near Term: Benefit or Risk?

Vaginal Examinations: A Symptom of a Cervical-centric Birth Culture

The Cesarean Rate Epidemic

This article looks at the current rates, state, and climate of Cesarean Births in the U.S. It provides statistics and rates, reasons for Cesareans, as well as the associated risks. 

“Cesarean delivery may be a safe alternative to vaginal delivery but its use in 1 of 3 women giving birth in the US seems to high.”

— contemporaryobgyn.modernmedicine.com

An excerpt discussing the rising rates and unusual number of Cesarean rates below:

"One possible reason for the rise in the cesarean delivery rate may be that there has simply been a rise in the need for cesarean. The most common indication for a primary cesarean is cephalo-pelvic disproportion, or arrest of progress in labor. It is unlikely that maternal pelvis size has changed over the past 3 decades, but it is possible that birth weight has increased. In fact, evidence suggests that rates of macrosomia have increased over the past 2 decades.8 Other issues that contribute to increasing rates of cesarean delivery, possibly through the mechanism of birth weight, are maternal obesity and gestational weight gain.9,10 Without question, the proportion of obese women has increased over the past decade and higher weight classes are associated with even higher rates of cesarean.11,12 In addition, increased gestational weight gain has been associated with cesarean delivery and is commonly above standard guidelines.13

Another reason for increasing cesarean rates may be a rise in elective cesarean delivery, also known as cesarean delivery by maternal request (CDMR). Because there was no ICD-9 code for CDMR, it is unclear what proportion of cesareans are due to it. One recent study, however, estimated the proportion as high as 4% in the United States.14 Interestingly, CDMR is more common in other countries, such as Brazil, Taiwan, and Chile. A study in Chile comparing women receiving private care (cesarean rate >40%) to women receiving public care (cesarean rate <20%) found that 8% of those receiving private care and 11% of those receiving public care stated a preference for cesarean delivery, with the vast majority preferring to deliver vaginally.15 Thus, even in this setting, it is unclear that maternal preferences are driving the increase in cesarean delivery rate."

Full article can be read here: http://contemporaryobgyn.modernmedicine.com/contemporary-obgyn/news/cesarean-epidemic-are-we-too-quick-cut?cfcache=true

Why delay cord clamping?

Science and Sensibility, the research blog from Lamaze, has an excellently evidence based article on the practice of delayed cord clamping. The article is structured by listing objections, which is a great way to go about learning the benefits, as well as to be prepared to answer to someone's concerns about this practice. Delayed cord clamping is becoming so much better understood and common place. Many Ob and midwife practices in Brooklyn and NYC do this as a matter of protocol. 

Read the full article here. 

VBACs are more likely successful if you call the midwife

A new study shows that VBACs (Vaginal Birth After Cesarean) are more likely to be successful if a midwife provides the care instead of an obstetrician. 

You can read a portion of the abstract of the study here, and an excerpt is below:

Background

Research is yet to identify effective and safe interventions to increase the vaginal birth after cesarean (VBAC) rate. This research aimed to compare intended and actual VBAC rates before and after implementation of midwife-led antenatal care for women with one previous cesarean birth and no other risk factors in a large, tertiary maternity hospital in England.

Conclusions

Implementation of midwife-led antenatal care for women with one previous cesarean offers a safe and effective alternative to traditional obstetrician-led antenatal care, and is associated with increased rates of intended and actual VBAC.

What A Doula Does

I adore this blog post written by my dear doula colleague, Yiska Obadia. You can read an excerpt below, and the full article here.

"Doulas are there to serve their clients. You want to birth naturally? I will support you. You want an epidural? I will support you. You want an epidural and to avoid a c-section? I will do my best to help you achieve that. Doulas serve our clients in helping them to achieve the birth THEY want as well as supporting them wholeheartedly with the birth they get."

From Spinning Babies... The Sacrotuberous Ligament: Key to Unlocking a Long Labor

This article is definitely worth a read if you are pregnant and preparing for labor. And especially if you are interested in anatomy! According to the article, it may be particularly applicable if any of the following are present:

• A long and difficult labor in which normal remedies (Rebozo Sifting, Position Changes, Spinning Babies Maneuvers) are not fully effective

• Persistently malpositioned baby

• Highly athletic mother (especially those who are highly athletic into their pregnancy)

• History of any trauma in which the ligaments of the pelvis could have been affected (accidents, falls, etc.)

• A visible Pelvic Upslip: One (usually left) iliac crest superior to the other, one leg (usually left) functionally shorter than the other.

NYC's Newest Birthing Center at LOMA

Finally, earlier this year, New York City unveiled a new in-hospital birthing center. Until recently, our only in-hospital birthing center was the Birthing Center at Mt. Sinai West (formerly known as St. Luke's Roosevelt). As of this winter, women have another in-hospital birthing center option: The Birthing Center at New York Presbyterian/ Lower Manhattan Hospital. I had the pleasure of attending a birth there as a doula just a few weeks ago, and the facilities are beautiful! (Not to mention the birth, too, of course!!)

Hopefully this trend will continue in NYC. There are so many women looking for low intervention birth settings, with the option to labor in a tub amongst other great options available in the birthing center. NYC residents also have the option to give birth at the Brooklyn Birthing Center, an out-of-hospital freestanding birthing center, and New York City's only independent birthing center.

Read more about the opening of Lower Manhattan's Birthing Center here.

A secret to a quick and easy childbirth?

There is certainly not one quick and easy solution that's going to work for everyone. I also don't even believe that this is THE way to go, but I have seen scenarios in which women do completely ignore the fact that hey are in labor, whether intentionally or not, and give birth quite smoothly and swiftly. But this is not to discount the women who need to focus and actively think in one way or another. There is no one right way to birth. But I think this article raises some interesting points worth thinking about.

Read the article here:

http://www.dailymail.co.uk/health/article-3147111/The-secret-quick-painless-childbirth-Just-don-t-think-ban-partner-room-leading-doctor-claims.html

Can a midwife administer pain medication?

For a hospital birth, whether or not a midwife can administer pain medication depends on what kind of pain medication we're talking about. For a home birth, it depends on the midwife. Read the article from Choices in Childbirth to get more information:

Can A Midwife Administer Pain Medication? By Barbara Sellers, CNM

Home Birth: The Latest Article with Some Statistics

If you haven't come across it before, Lamaze's blog, Science and Sensibility, is a great way to stay up to date on recent studies and new information in the maternal/perinatal health world. I recently came across this article and wanted to share it.

How to Avoid an Episiotomy in Birth

I have not yet met a woman who does not want to avoid an episiotomy in birth!! Read on below to get some tips on how to avoid this unwanted procedure, published by Choices in Childbirth.

ASK THE MIDWIFE: HOW CAN I AVOID AN EPISIOTOMY DURING BIRTH?
FEBRUARY 16, 2016

Childbirth, Midwifery, Nutrition, Pregnancy, Sexuality

“How can I avoid an episiotomy during birth?”

Today an episiotomy is no longer a routine procedure – thank goodness – but is performed for cause. Some reasons include a tight perineum which prevents the baby’s head from distending the perineum, prior scarring of the perineum, female circumcision, and/or the baby’s heart beat is low and delivery needs to be expedited. We can decrease the problems with the perineum but not some of the other causes.

The other question is how to prevent natural tears of the vagina and the perineum. It is important for women to know that there is a group of muscles in the vagina that support the vagina, bladder and rectum. These muscles need to be strengthened and toned prenatally to increase their elasticity to allow for relaxation of the vagina and perineum during birth. These same muscles need continued exercise for the remainder of our lives. Thank Dr. Kegel for giving us the Kegel exercise!!

Proper overall fitness is important so consider walking and squats for toning. Proper nutrition is also key. Make sure that you get adequate protein and other nutrients for your tissues to respond well to the stretching of birth.

Keeping the vagina healthy and reporting any signs of an infection to your provider promptly to maintain good vaginal tissue integrity is hugely important. Perineal massage is advocated by many to be helpful in preparing the vagina and the vaginal muscles for birth. This needs to be initiated at 34 weeks and done for approximately 5 minutes 3-4 times per week.

When it comes time to push, your position is important, as is the use of warm compresses on the perineum. The lateral position or squatting for birth is protective of the perineum.

Finally, a slow, controlled delivery of your baby’s head will definitely help to decrease tears. This is difficult when you have a very strong urge to push. I recommend practicing techniques learned in childbirth classes such as focused relaxation.

Susan Papera, CNM,MSN received her undergraduate degree from Cornell University and her Master’s degree and Midwifery from Columbia University. She joined the staff at NYC Health + Hospitals/North Central Bronx as a staff midwife shortly after the Obstetrical services were open in 1978 and she has been helping to care for the women and families in the Norwood section of the Bronx ever since. Presently, she is Director of Midwifery Services. Working with such a richly diverse group of women is extremely rewarding and also an on going learning process as she says. Ms Papera is particularly proud of the fact that she is an NCB “Grandmother”- babies she has helped into the world are returning and she has had the privilege of helping their babies into the world.

Midwife Thinking: Birth From the Baby's Perspective

Such a fascinating article! Excerpt below, and definitely head over here to read the article from Midwife Thinking in its entirety, as well as watch the videos.

Here are the bullet points from the article on treating a newborn with respect:

"A humane approach to welcoming a baby to the world

Whilst in some cases it is not possible, I believe that we should aim for all babies to have the opportunity to:

• Make their own way through their mother’s body and into the world (ie. no unnecessary pulling).
• For their first touch to be from the hands of a person who loves them (mother, father, family member, friend).
• To be held immediately by their mother skin-to-skin.
• To be sustained by their placenta until the placenta stops functioning (ie. leaving the cord intact).
• To be left in peace to find their mother’s nipple and latch on.
• To be treated gently and with dignity and respect during any ‘checks’ that their mother chooses to have done."

New Birth Plan Template

Many of my birth doula clients - whether they are planning a natural birth in a hospital or birthing center, or birth with medication, or a home birth - want to create a birth plan. One hospital in NYC (NYU) provides a fairly succinct birth plan template, which is great, however I don't know many other hospitals that do provide a template. You can find some templates online, some simple and some that are pages and pages long (which I don't recommend). The image above is of a new one that I came across and thought I'd share - link below. Enjoy!

https://thebestseasonofmylife.wordpress.com/2015/08/20/a-downloadable-visual-birth-plan/

Birth Matters.

I love this article! Read the full text here.

Excerpt below:

"The problem with saying “It doesn’t matter how you give birth” is that if women take that to heart, they may not take the time to educate themselves on their choices or vet potential providers to find the right fit since the birth process doesn’t really matter anyway. Empowerment starts with women educating themselves on the childbirth process and understanding that they are the drivers of that process. Birth attendants are primarily experienced navigators who know what to do if inclement weather hits or if the car breaks down. They should not take the wheel unless there is truly no other choice.

Childbirth is the likely the hardest, most overwhelming thing a woman will ever do, so of course those experiences matter. If you walk away from your birth feeling powerless, that’s important. No matter how your baby ultimately enters the world, how you experience birth and how empowered you feel throughout the process does matter. Let’s stop telling women that it doesn’t."

Placenta: Essential Resuscitation Equipment

When people hear "placenta" these days, they may tend towards thinking about placenta encapsulation. What about the placenta's role and potential as the baby is born? This is fascinating article on the placenta, delayed cord clamping, and newborn resuscitation. It's a little bit birth-nerdy, but if you are interested in cord clamping and your newborn's transition to breathing on her/his own, please have a read!

Read the full article here from Midwife Thinking.

The Forgotten Art of Untucking The Tail

Very interesting as it relates to birthing a human...

“Modern birthing science has placed a large burden on secreted hormones (like relaxin) to prepare the body for needed mobility.” Katy Bowman says. Yes, hormonal relaxin is useful in letting the body open up for the birth, but it’s not enough, unless we have strong muscles that can fully contract, but also fully release. But then, strong isolated muscles are not enough either. In order to have smooth births we need to have a whole-body endurance. A great way to develop endurance is to walk as much as you can. “The woman who wants to go about a birthing process naturally can follow the lead other “natural” processes women have been doing for millennia — walking 5–6 total miles per day, and squatting to bathroom multiple times daily” — she adds.

Read the full article here.

Evidence Based Care for Pregnant Women

Ever wonder what evidence-based care is? This great free video series by Rebecca Dekker, PhD of Evidence Based Birth does an excellent job of explaining what evidence-based care is and how to get it. A must watch video series for expecting parents - even if you are not pregnant yet! In fact, the sooner parents-to-be have access to this kind of information, the better. Whether you are interested in a natural birth, home birth, hospital birth, cesarean birth, birth with a doula, or birth without a doula, midwifery care or medical care model, this video series is for you! There's also a great video on the evidence for birth plans. Very enlightening. Enjoy!

Click here to watch the Evidence Based Birth video series: Do Birth Plans Really Work?

YOUR BIRTH, YOUR CHOICE!

Seriously! As a doula, I support my clients' personal choices. Only each woman can know what is right for her when it comes to choosing a birth location, a care provider, and what type of care she would like to receive. There are so many different ways to give birth, which is wonderful, because there are so many kinds of women!

I love this quote from this recent article that explains some of the current controversy going on in the birth world:

How and where and whether someone has a baby is, by and large, every bit as personal as the business that led to conception in the first place.

Isn't that the truth?

Read the full article here.

Stop Telling Women that Birth Plans are Pointless

Excerpt from this great article by Milli Hill:

Yes, birth is unpredictable, but don't let that fool you into thinking the whole thing is just pot luck. There are elements that you can include in your birth plan that will maximise your chances of having a positive experience. They won't be a cast iron guarantee (remember that bit about how life sucks?). But they will maximise your chances.

Birth plans are not just idyllic wish lists lit by pretty tea-lights and trimmed with home-made bunting. A birth plan is a chance to take a detailed look at the huge amount of choices and options available to you, to consider the many ways birth might unfold, and to really make sure your voice is heard in the labour room. "Don't offer me pain relief unless I ask for it." "Keep voices and lights low" "Delay cord clamping" "I don't want V.E's" "Immediate skin to skin" "Husband with me in theatre" "Yes / No to Vitamin K", the list of options is endless and worthy of a great deal of time and consideration. Read the article in its entirety here.