Frequency of vaginal exams during labor

[BETSRN]

I just figured I would start a thread that will be good for students to read also. At our facility, we really keep lady partsl exams to a minimum. They really are not necessary much, anyway. In my childbirth classes, I also teach about how frequent exams can increase the risk of infection, etc. Consequently, we do as few exams as possible (that includes the docs and the midwives) :rotfl: on my unit. What are the rest of you out there doing as far as frequency.

My motto always is "if the head hangs out, she's fully dilated." There is no need to know that she was 5,8,or 9 cm in the process because it really doesn't matter. Our docs pretty much stay away until we cal them (for the birth).

[RaeT,RN]

First of all -THANK YOU. I try to minimize my SVE's at all costs, and have miffed at least one doc in doing so. (Now, part of that may be that I am not completely confident in doing vag exams yet, but that's beside the point! ) No, seriously, though - it is the same treatment I would want for myself and my family members, so . . .

Secondly - as a new grad who is in the next week or so coming out of orientation - use your experienced nurses and charge nurse as a resource! To be perfectly honest, I just two weeks ago started to feel more comfortable with my vag exams (actually, now that I think about it, I am darn sure when I'm feeling 4cm, but I'm not sure if I recognize anything higher!:imbar ) Anyways, everybody knows that that's not something you "get" right away, and most nurses are more than willing to help! Good luck!

Edited to say: And what is up with pushy family members, anyway????? It's like, "chill, you're gonna be here for a while."

[SmilingBluEyes]

Statistically, you have about 6 VE's before infections risks significantly rise in SROM/AROM'd moms. I can't remember where I have read that, but I have, several times. Meaning, KEEP VE's to an absolute minimum. Watch for other clues...like changing fetal heart rates/lots of early decels in moms w/epidurals...or in moms w/o epidurals, TRUST THEM, they will KNOW when it is time.

It's rare a baby will sneak out on ANYone, even w/an epidural in place.

wooops I just noticed, this is an old thread to which I had already responded. Well I still stand by what I said first time around ...grin.

[Dayray, RN]

Like many things my opinion has changed on this over the last year or so. Here is what I do.

Natural patient. On admission, when I think they are getting close to complete (with a multip), when they want to push (with a primip), also sometimes if they ask. Many times natural patient’s only get 1 or 2 checks the whole time because it’s so easy to read their cues. Things are so much less complicated with a low risk natural patient ahhh how I wish I saw more of them.

However, where I work we have a 95% CLE rate and nearly that high with pitocin. We also have a huge amount of induction’s and our patients very often have something that qualifies them as high risk (weather made up or real). I even have nurses and docs that try to get me to start pit on my patients that are progressing normally or to place IUPC's. They have become so used to interventions and high risk that they automatically default to every intervention in the book.

Sorry I'm drifting from the subject here. What I started to say was that, because of this high intervention rate and the fact that we are unnaturally pushing the patient into labor as well as masking their natural cues with epidural I end up checking every 2 hours.

A good rule of thumb is that you only check if the findings are going to change your course of action. In the case of a patient with every intervention in the book, your course of action is going to change based on dilation much more often then with patients who don't have pitocin, epidural, etc.

With pitocin I have found it much more prudent to base your rate of pit on cervical change rather then on MVU's. I have seen many patients that progress well with contx Q 5 min and MVU's of less then 180. If they are progressing well and you start pit (even if their MVU's are less then 180) you are going to stress out that baby and risk running to the OR. So I tend to skip an IUPC and just check every 2 hours. I've had other nurses angry with me when I'm giving report "why didn’t you start pit? Or put in an IUPC?" and I answer "because she has gone from 2cm to 8cm in 4 hours" of course when I walk out the door they get internal monitors and start pit. I guess you can add risk of infection to the list of downsides of induction’s. Still I'd rather risk corio then fetal distress.

I recently had a heated debate with a CNM who didn’t want to check a ruptured patient who was not contracting prior to starting pitocin. She sited the Ireland studies as a basis for her decision. Yet those studies are based on low risk, young patients without an epidural and with a midwife continually present in the room. I have seen many of her patient’s end up in the OR because she likes to run pit and an epidural without checking them often. The fear of too many vag exams has cost her patients too much.

Just the night before, I took a 19 yo primip to the OR because she hadn’t checked her in 12 hours. I came on shift to repetitive late decels. I checked her cervix and it was 3cm the pitocin was on 4 mu a min (based on adequate contx on the toco). Sure she was contracting but it wasn’t changing her cervix and after 20 hours of contraction the baby was worn out. I got the late decels to go away, did some position changing and increased the pit once baby had recovered. She eventually got to complete and we had to have the OB come in because tones went down with pushing. She ended up with a failed silastic a 3rd degree and then a P C/S on top of it. There were other bad decisions made but I won’t go into all of them here. It really bothers me that this little girl will have to worry about VBAC vs. C/S with her next child. It just plain tics me off that she will have to deal with both a painful tear and an abdominal ins. It's just not right, with good care she would have had a vag birth.

Yes low intervention (in most cases) is better. However, I don't see that you can have extensive interventions and limit your vag exams. Induction and augmentation is an artificial process. In order to guide it properly you need to monitor closely.

[cinnyluvscats]

I last worked OB in 1996, so my info may be dated, but I used alot of the same guidelines to decide when/if to do VE that have already been talked about here.

I was big on Friedmann curves. When I started to suspect that her labor progress was slow, she was high-risk, or my nursing intuition said to start one, I did. The docs appreciated it because they had info in a summarized form that helped with making clinical decisions and the couples could also get a "picture" of what was happening.

Just putting in my 2-cents worth!

Cindy