Internal Examinations

[ItsAllGoingToBeFine]

This will be my first and due to various issues I think I am likely to find the whole state of undress thing fairly traumatic. The last thing I want is to have a midwife giving me internal exams as well. (I find smear tests painful, invasive and humiliating)

Are they necessary? As far as I was aware labour takes as long as it takes, therefore degree of dilation is more for interest?

And surely if the baby is in distress it'll be picked up by heartbeat monitor, and is not related to dilation?

If I were to refuse routine internal exams what are the implications? Under what medical conditions might they be definitely required?

I thought I'd feel like that about internal exams too - I'd always found smears painful and nasty experiences. In reality though, you'll probably find you go into 'survival mode' during childbirth. All you will be focussing on is getting your baby out as safely and with as little pain as possible. You won't care as much as you think you will about what would normally be quite a humiliating procedure.

The midwives sent me home as I was only 2cm dilated - they wouldn't have known that without an internal exam. Later on, I had no urge to push so they had to check that I was 10cm first.

You could always put on your birth plan that you would prefer minimal examinations, but play it by ear - you may find on the day that you want to know how everything is progressing.

Good luck!

sorry i don;t know the answers to all your questions but i just wanted to say i think it is worth pursuing the idea of having no internals
with both my births i had early and painful internals that left me demoralised as they showed i was not very dilated
i did not want any internals with my second and wished i had stuck to this- i don't think they are necessary unless something out of the ordinary is happening, but they are given routinely and i don't think they help labouring mothers

have you considered getting a doula to help with the birth? you are a lot less likely to be given unnecessary internals (or to need them because of complications) if you have a trusted and knowledgeable woman there with you
i don't wish to frighten you but if you are unduly nervous about aspects of the birth it could be a difficult time for you - a doula can support and calm you and be an intermediary between you and the midwives who want to do all sorts of intrusive things to you as routine

ultimately it is up to you
best of luck

I think internals are best avoided if possible but they may be important for a number of reasons. As Cuppatea mentions, you may not actually need to be in hospital (say you are 1 or 2cm) and an internal could send you happily home. Or, more importantly, if labour is taking longer than we would expect (it does not simply take as long as it takes - it is bloody hard work and no-one can labour indefinately), an internal may determine the course of action we suggest next. We need to be sure that progress of some sort is being made, it would be negligent to leave you labouring with no progress, your body can only cope with so much. Changes to the fetal heart I would be happy with at 10cm, I may be concerned by at 3cm and the same for a 'bloody show' which if you were fully dilated would be fine but if you were 2cm would not.
It can also help to determine the position of the baby and whether membranes have ruptured, information which may be useful to you and your care givers.
Internals may also be part of any induction process you may experience. Impossible without tbh.
Midwives know they are not pleasant, so we do try as hard as we can to keep them to a minimum and make them as easy to bear as possible. Good luck, you may turn up to the hospital 8cm and the need may not even arise!

I felt the same as you but will always be thankful I had 1. The midwife said something was not right, they gave me a scan, discovered ds was breech and got him out soon afterwars. If I had not let them they may not have known till I started to push.

I has gas and air when she did it which helped.

Umm, girlylala, do you realise that vaginal breech birth is entirely possible and not necessarily any more difficult or dangerous than the other way up? See Mary Cronk for some details.

I'm hearing quite a few people on here saying they had emergency for breech when some buttocks began to show - and it's beginning to piss me off that that is seen as the normal thing to do for breech.

Anyway, *Itsallgoingtobefine" back to topic:

You can put in your birth plan "No VEs", or "No VEs unless I ask for them", or maybe "No VEs unless there is an extremely good reason for them". They have to ask your permission every time, so you can say no. But that can be a difficult thing to do if you have very authoritive midwives/doctors saying they need to. It's good to let them know that you are really not happy about having them, that way you give them the chance to be as sensitive as possible about it.

Second birth I got away without having any, but it was a relatively quick homebirth. I put "minimal checks" in my birthplan.

Try and have the least you can get away with anyway - they can be very disruptive to your labour (you have to be in a bad position, it can make you tense up etc).

And if you are labouring away in an upright position and you get persuaded to have one, make damn well sure that they get you back up into your prefered position afterwards! Even if they have to physically lift you. Don't get trapped on your back.

Oh bugger, got me bolding wrong, should've been ItsAllGoingToBeFine.

Hey Smilehomebirth,

No I never knew that,

They saw ds was breech, they said c-section, I said can you do anything else and they said no. I did not know any differently.

and damn well sure. Damn, I'll get there in the end

Ooh, the buggers. I really think they need to start educating themselves about normal breech births, might cut down the unnececaesarians a little.

Im actually quite upset now.

I really had no idea at all.

Why does nobody tell you these things.

Sorry for hijack

Surely they can tell if baby is breech by prodding abdomen!? At my last check she told me where the various body parts were just by prodding - baby kicked her back .

I always thought if it was both feet first, or bum first then a vaginal birth was perfectly possible?

But then my hospital has a 25% caesarean rate.

As for tensing up for a VE, thats a given. The nurse struggles to get the speculum up and thats tiny

Breech births may not be any more dangerous than a cephalic birth if you have an expereinced practioner there to help you. So in that case it would be helpful to know before buttocks are visable so they can select a senior m/w to look afetr you. Or call the consultant in if its a weekend. Not for a section but just so there is an expereinced doctor on the ward if needed.

I've been a m/w for 5 years and have never seen a breech birth. If I saw buttocks I'd pull the emergency buzzer, 'cos even though I've practised manoevers on a dummy baby before I would not want to be by myself having a go on a real baby. I do agree that its a shame that breech births are now emergencys and wish it hadn't come to this state but now they're so rare I can see why they are. If we had more experienced m/ws and Drs maybe there wouldn't be so many sections for breech?

VEs can also determine position of fetal skull so can pick up a brow/face presentation which can be important and can't be picked up on palpation.

ItsAllGoingToBeFine - unfortunately palpation isn't an exact science and I think its nearly 50% of babies who are breech at term will be undiagnosed. DD1 was breech - we had the good fortune to know in advance and so were able to plan accordingly. After doing a lot of research we concluded that vaginal breech wasn't intrinsically dangerous - but vaginal breech without MWs or Drs competent and confident in breech birth was. In order to guarantee those skills we used IMs and had DD at home. It used to be standard to consider a breech presentation as "unusual" but normal - since a study published in 2000 though, CS has become standard practice and breech skills have declined. Even though the paper has now been discredited, bringing back the breech skills will require a change in policy throughout the NHS, and so far that isn't happening

Re. VEs, with DD1 we had IMs so I had a MW who I knew with me from about an hour after I went into active labour through to post-delivery. She knew me and was able to stay with me and just observe how I was labouring. I had no VEs at all. With DD2 I had hoped to have a similar experience, but for various reasons I had to be induced in hospital and so had a number of VEs - 2 to insert the prostin gel and 3 more to check progress. I won't say I enjoyed them, but I made sure that I understood exactly what they were trying to find out why they needed to know that information. It didn't make it any more pleasant (although the MWs were very gentle), but at least I could see there was a genuine reason related to my wellbeing and that made it easier for me to accept.

Hello! I just wanted to say that I totally understand.

I have always been a nightmare for smears and would often go overdue and I have been know to get up off the table and leave the surgery without saying a word to the doctor as he has approached me with a speculum in his hand.

I have also fainted and vomited after internal examinations and have been the person sitting in the waiting room with my head between my knees taking deep breath even though I've been told I'm healthy down there and can go home.

My point is, I was induced and laboured for 25hrs. I was in a teaching hospital which meant that during this time I had a ridiculous amount of people putting their hands in me. In hindsight I should have told them to piss off.

But, despite my past behaviour, I was able to tolerate the examinations as all I could think of was my baby. The contractions hurt, you're knackered and all you want is to get your baby out safely and each time they examine you, you want to hear the baby has engaged and you are dilating.

So take the advice from other posters, if you feel that strong at the time then tell them no examinations unless it's absolutley necessary. But also keep an open mind, you may surprise yourself and find that you can tolerate them. Having a baby is so exciting and mixed with the pain and knowing what's to come you may be able to shed your usual negative associations with internal examinations.

BTW, I still feel exactly the same about standard internal health checks. I cannot bear to think of my forthcoming smear test and I hope I can bring myself to go through with it.

Best of luck

To the original question, I'm sorry but it has to be done, to know if you can start pushing yet, they need to check the cervix is over the head, or to push could cause great problems.
I remember with my first a big man doctor did it and it hurt and was horrible :-(
but after the birth I could barely care.
You know the midwife has to reach her entire hand through your vagina into your uterus after birth? to check the womb wall is clear?
Or am I mistaken?

Oh gosh, way to worry someone even more, ignore me!

mummyof2byapril - I think you might be slightly misinformed. It may be policy in some PCT's to check for full dilation before advising a mother to push and, as you have said, there are reasons why it might be recommended - but just because something is policy doesn't mean it has to be done. I didn't have a VE for this purpose with either birth, and neither was it suggested. I've seen it suggested that if the mother follows an urge to push but there is no obvious progress then that is a point when a VE may give a lot of information about why. Once the placenta is delivered they will check that it is intact, but to the best of my knowledge it is not standard practice to manually check the uterus after every delivery (again, it didn't happen with either of my births and neither was it suggested).

I found the MWs were very sympathetic and very happy to wait for a gap between contractions to do whatever needed to be done (although me not lying down till then might have had something to do with that as well!) You don't have to lie down for them, either, but my understanding is that things do feel a bit different depending on the position of the woman - so if the MW doesn't have experience it may not be the best solution (although you can ask if there are any other MWs with that skill).

I'd agree with the doula suggestion. Or look at Independent Midwives - they are expensive, but all of the ones I've heard of are very happy to sort out payment plans and/or look at some exchange of skills or services (ours was desperate for a decorator, IIRC).

I promise you its not true about the m/w having to put her hand into your uterus to check anything afterwards. They will want to check afterwards to see if you need any stitches but that only involves parting the labia to have a good look at your vaginal wall.

Reading the OP again I'm wondering if it might be an idea for ItsAllGoingToBeFine to have some counselling before the birth, as it sounds like a wider issue for her than simply the internal examinations. She mentions finding the idea of being in a state of undress traumatic.

Even if internal examinations were refused, there may well still be the need for midwives to be poking around down there, such as episiotomy, forceps, stitches or simply checking everything is healing well afterwards.

There are many reasons why some women might find the psychological aspects of medical interaction during childbirth traumatic - from rape and abuse to religion and upbringing, and maybe these need addressing in more detail if women are to have a 'pleasant' birth experience. Sometimes it's not as simple as just refusing internal exams.

I think I have come to accept that lots of aspects of childbirth are going to be fairly difficult for various reasons. Whilst not at all comfortable flashing my bits at people (inc my DP ), I accept that it is totally neccesary for that area to be unclothed. This is non-negotiable and I understand that.

The internal exam thing does appear to be negotiable(ish) therefore I want to minimise it at much as possible without causing any harm to myself or baby. Your posts have all been really helpful to me in clearing up what is "reasonable" for me to ask for.

I guess a lot depends on the midwife at the time, and I'll just explain that i am incredibly uncomfortable with the idea, to the extent that I am concerned that VEs might cause issues with my labour and go on her reccomendations and hope she is nice. It's not the pain I'm worried about BTW (can't hurt as much as pushing out a baby), its more the whole on your back invasive, humilation thing.

cuppaTea I have thought about the counselling thing, not particularly for the birth but in general, but being british I just don't do that sort of thing . If I do have issues related to certain events they were all a very long time ago, and nicely buried which is a good think I think.

I always read whole threads, but can't now. I just wanted to say that while I too have a horror of internal exams, and found them the worst bit of my long and complicated first labour I put a note explaining this in my birth plans for subsequent births.

For both subsequent births, midwives took this totally seriously and gently talked me through minimal examinations ...

I can now have a smear without freaking out. Do explain it to the midwives and I hope you get the kind of support I was lucky enough to receive (in two different hospitals btw)

girlylala - sorry, didn't mean to upset anyone . With hindsight it's annoying, but you never know, your baby might have been one of those breechs best born by caesarian anyway.

I would recommend getting this documented in your notes and agreed with as senior a person as possible (ideally a Consultant midwife if your hospital has one) to avoid having to explain all this while you are in labour and may not feel like talking.
One way of dealing with the stress of being in a 'state of undress' is to use a birth pool, this can make you feel less exposed, safe and 'cocooned'. And you dont need to be naked in that either, you can wear a t shirt or nightie.
I also second the idea of having a Doula to support you (see www.doula.org.uk/utilities/userServices/search.asp to find one near you)
Selina

Plucked up the courage to ask midwife about this in antenatal class today (so no heart to heart/explanations etc).

I asked what would happen if I were to refuse VEs as I had an issue with them.

She told me that I was welcome to refuse, but they would then call in a more senior doctor who would "persuade" me that it was necessary.

After reading all your comments I am feeling a lot more confident about asking for what I want (thanks!). The midwifes comments about bringing in someone senior to persuade me have scared me a bit, but I am planning on going through my birthplan at my next m/w appointment so will try and bring it up and discuss properly then.