• How Frequently Should A Woman In Labor Have An Internal Exam?

    A certified doula, Lamaze coach, and midwife, Debra Flashenberg explains the benefits and risks of internal exams during labor.

    By Debra Flashenberg

    A new mother came to postnatal yoga last week absolutely glowing and excited to share her birth story with me. The happy mama said she really felt good about her birth experience, but with the exception that she wishes she would have been checked for dilation before receiving an 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 was, “How am I going to do this for much longer?!” She immediately requested an epidural. It was only moments after the pain relief set in that she felt incredible pressure in her pelvis. The doctor checked and she was fully dilated and the baby had descended quite low in her pelvis. Low enough that it took only about 10 minutes to push her baby out!

    She explained that in hindsight, she probably would have foregone the pain meds (which was her original intention) had she known how close she was close to the end.

    It’s important that the new mom felt good about her birth experience, however, there’s a lesson to be learned. If you’re considering an epidural, it’s 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’s my take on reasons for requesting an internal exam.

    1. Baseline Assessment
    When the woman first arrives at the hospital or birth center it’s 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 don’t want to admit someone in very early labor unless she’s prepared to take interventions to move her labor along.

    2. Concern About Progress or Position
    I’ve encountered several occasions where the mother appears to be in the throes of intense contractions and those around feel confident that she’s fully dilated, or at least well on her way. But upon examination, the mother has not dilated much. This would indicate the need to shift strategies, reconsider the baby’s position, and change activities before the mother exhausts herself. Dr. Gae Rodke from St. Luke’s/Roosevelt says that 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 the cord is not prolapsing and to confirm the position of the presenting part.”

    3. Considering Epidural
    As seen in the case of the new mother above, if you’re considering an epidural, you may want to get checked to see where you are in the labor process. Statistics show it’s not ideal to get it before active labor–although you don’t need an internal exam to determine you’re in early labor. But for those who are looking to have a medication-free birth, if you’re 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 is a bit controversial. As mentioned before, some birth purists don’t believe that internal exams are necessary or that a woman should wait to be fully dilated before starting to push. I agree that it’s important for the mother to follow her instincts. Although, in my experience as a doula–working in mostly hospital settings–the care provider usually wants the mother to be fully dilated before pushing. If the mother pushes and there’s still some cervix present, she can actually swell or lacerate the cervix. Dr. Rodke adds, “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’s some 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 Internal Exams
    Given the various valid reasons for a mother to have a vaginal exam, it’s good to be prudent in the number of exams the mother needs to endure. Here are some reasons why more isn’t always better.

    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 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 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’s important for there to be a reason for it. How is this information going to benefit or change the circumstances? As Dr. Rodke points out, there are legitimate reasons for doing an internal exam that can decide the course of action. Doing an internal exam to simply 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 can take 15 hours. It’s more important to look at how the mother and the baby are handling labor. Interestingly, some women can have dilation reversal, especially if they’re feeling scared, pushed, or threatened.

    This is also good advice when it comes to prenatal internal exams. It doesn’t do the mother any good to hear her progress, or lack thereof, before the onset of labor. If anything, this can be discouraging or cause over-excitement. I’ve 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 the same night.

    Armed with the knowledge of the benefits and the risks of internal exams, pregnant women should be able to make the right decisions for themselves. After all, it’s your birth experience, so the choice is yours. Happy birthing!

    Debra Flashenberg is the founder of the Prenatal Yoga Center. After spending much of her life in musical theater, she was introduced to yoga in 1997 and has since become a certified doula, Lamaze coach, midwife, and certified vinyasa yoga instructor. She is continuously in awe of the beauty and brilliance of birth and is the proud mother of baby boy Shay.

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