Internal Exams: When To Get Them

by Debra Flashenberg, IMI Advisory Board Member and Guest Blogger

A new mother came back for postnatal yoga last week. She was absolutely glowing and excited to share her birth story with me. The new mama said she really felt good about her birth experience, but with the one exception that she wishes she would have been checked for dilation before receiving the epidural. She arrived at the hospital at 4cm. For several hours she and her husband managed her contractions well. Then she said, all of a sudden they became unmanageable and all she could think about was, “How am I going to do this for much longer!” She immediately requested an epidural and received it quickly. She then explained it was only moments after the pain relief set in that she felt incredible pressure in her pelvis. The doctor then checked her and she was fully dilated and the baby had descended quite low in her pelvis. Low enough that it only took about 10 minutes to push her baby out!!

She explained that in hindsight, she realizes she was probably in transition. However, she or her husband had not experienced labor before and didn’t know what that looked like. She just knew she felt overwhelmed by the contractions, but said that if she had a frame of reference for knowing she was close to the end, she probably would have foregone the pain meds (which was her original intention).

Most importantly is that the new mama felt good about her birth experience. However, there is a lesson to learn for future births and for our readers. If you are considering an epidural, it is not a bad idea to ask for an internal exam to determine where you are in your labor.

The question of when and how often to get an internal exam comes up often in my childbirth education classes. Here is my take on when to get an internal exam.

1. Baseline assessment
When the women first arrives at the hospital or birth center it is useful to get a baseline assessment. Also, if the woman is not particularly far along, this may offer her the opportunity to go home. Most hospitals do not want to admit a woman in very early labor unless she is prepared to take interventions to move her labor along.

2. Concern About Progress or Position
I have encountered several occasions where the mother appears to be in the throngs of intense contractions and those around feel confident that she is fully dilated, or at least well on her way. But upon examination the mother has not dilated much. This would indicate that we need to shift strategies, reconsider the baby’s position, and change activities before the mother gets too exhausted. Dr. Gae Rodke from St. Lukes/Roosevelt adds an internal exam can be very beneficial “When something arouses concern, such as membrane rupture with an unengaged fetus or a Breech, to be sure that cord is not prolapsing, and to confirm the position of the presenting part.”

3. Considering Epidural
Just as discussed in the story above, if you are considering an epidural, you may want to get checked to see where you are in the labor process. Statistics show it is not ideal to get it before active labor- although you don’t need an internal exam to determine you are in early labor. But for those that are looking to do a medication free birth, if you are on the cusp, knowing where you are may help you make that decision.

4. Urge to Push!
Another notable time for an internal exam is if the mother is feeling the urge to push. This topic can bring a bit of controversy. As mentioned before, some birth purists don’t believe that internal exams are necessary or waiting to be fully dilated before starting to push. I do agree that it is important for the mother to follow her instincts. Although, my experience as a doula- working in mostly hospital settings- the care provider wants the mother to be fully dilated before pushing. One reason can be that if the mother pushes and there is still some cervix present, she can actually swell or lacerate the cervix. Dr. Gae Rodke adds, “Pushing before full dilation can cause the cervix to swell, delaying progress. A swollen cervix is more likely to tear, which can cause heavy bleeding and lead to emergency intervention and/or a difficult repair after the baby is born. The possibility of stretching pelvic supports leading to later uterine prolapse is another good reason to wait.” However, if there is still a bit a cervix lip still present, the care provider may help push it back over the baby’s emerging head and help the mother reach full dilation.

Reasons Not To Have Too Many Exams:
Listed above are very valid reasons for the mother to have a vaginal exam. However, it is good to be prudent in the number of exams the mother needs to endure.

1. If the mother’s water broke, multiple vaginal exams it can introduce bacteria and lead to infection

2. Vaginal exams are subjective, so if being performed by multiple people with differing results, this can be discouraging for the mother

3. If the exams don’t show the progression the mother was hoping for, it can be discouraging

4. Vaginal exams are uncomfortable

5. A rough vaginal exam can lead to the woman’s water rupturing

6. Regular internal examines can make the woman feel like she is on a schedule, like she must hit certain marks within a certain time. This is especially true in a crowded hospital where there may be time protocols as to how long a woman can be in labor for before introducing interventions. It would be better to look at the laboring woman for signs of change instead of a clock.

Most importantly, when performing any type of procedure or exam, it is important for there to be a reason behind it. How is this information going to benefit or change the circumstances? As Dr. Rodke pointed out there are legitimate reasons for doing an internal exam that can change the course of action taken from the results of the exam. Doing an internal exam just to try to predict how much longer labor is going to be is not very effective or accurate. Some women can go from 5cm to 10cm in an hour, others it could take 15 hours. It is more important to look at how the mother and the baby are handling labor. Interestingly, some women can have reversal of dilation, especially if they are feeling scared, pushed or threatened.

This is also good advice when it comes to prenatal internal exams. It does not do the mother any good to hear her progress or lack there of before the onset of labor. If anything, this can be discouraging to some women and cause over-excitement for others. I have seen many women walk around partially effaced and dilated for weeks before labor starts. While others see the doctor that morning, hear that nothing is happening and then go into labor that night.

I hope my take on internal vaginal exams has been useful to you. Happy birthing!

About Debra

Debra, founder of Prenatal Yoga Center in NYC,  has studied with renowned prenatal yoga teacher Colette Crawford, R.N., at the Seattle Holistic Center. Debra has received certification for Vinyasa Yoga from Shiva Rea as well as completed the OM Yoga advanced teacher training with Cyndi Lee in 2004. Debra has also studied the Maternal Fitness Method with Julie Tupler. Debra currently studies with Cyndi Lee, Genevieve Kapular, and Carrie Owerko.In 2006, Debra received her certification as a Lamaze® Certified Childbirth Educator. In September of 2007, Debra completed a Midwife Assistant Program with Ina May Gaskin, Pamela Hunt and many of the other Farm Midwives at The Farm Midwifery Center in Tennessee.

Disclaimer: The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of  the International Maternity Institute.

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