Frequency of vaginal exams during labor

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    I just figured I would start a thread that will be good for students to read also. At our facility, we really keep vaginal 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) 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). :hatparty:
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    When I did L&D, we tried to minimize vag exams too. Generally they would be done on admission (because under 3cm and we would try to send them back home) and before certain procedures like epidurals (cause we wouldn't place them in women under 3) and when we thought women were complete (had a few trying to push at 7cm with a midwife) and if there was fetal distress. We only did it to check progress if it had been a long time and the women were on pit.
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    Minimizing vag exams makes so much sense, for obvious reasons (to me, anyhow).

    I prefer to NOT put a mom in discomfort for NO good reason. Vag checks can be supremely uncomfortable or painful. We need to remember these are human beings we are treating, not lab rats for experimentation or practice.

    Also, to keep chances of infection down, minimizing vaginal exams is a must. No matter that you have a sterile glove on, and use sterile technique; MOM is NOT sterile and any microorganisms in/around the introitus will be advanced up with each vaginal exam/instrumentation (internal monitors, etc) done. Our doctors do differ in opinion from me. They want vag exams q2 hours while a patient is in labor, so as to see if they fall off the Friedman Curve. I think that is a bad idea and I was trained quite differently. Some people WILL fall off the curve, only to "break free" and proceed rapidly later on. This is something I observe time and again, especially after a person reaches 4-5 cm in dilatation. Only a couple reasons exist that make me want to vaginally check my patients:

    1. The Mother feels "different" or "pushy" or lots of pressure. Moms are instructed to report these things to me, especially if they have labor epidural anesthesia. If Mom feels "different" or vomits, there is a BIG clue to check things out. (duh heheeh)

    2. Baby looks bad on the monitor, e.g. repeated decelerations that are variable or late in nature. May indicate quick progress, or not-----but you need to know progress when fetal or maternal status changes. It can be based on these findings, what interventions must be undertaken and what can be put on hold for the time being.

    3. To establish a baseline------often I will ask them what the doctor found their dilatation to be in the office and then I check them initially (IF contracting/to rule out labor) to see if there is significant change.

    I believe, especially when membranes are ruptured, it is critical to minimize putting our hands in the vagina. I read someplace (can't remember where)---statistically, we have roughly SIX checks before we significantly raise the chances of infection in the mom. Bad deal and not worth it to me.

    The experienced clinician knows labor progress can be measured other ways: e.g. how a mom feels, by the way the fetus' heart tones look on the monitor, etc. Time and nature take care of it in most cases, IF we let them. My rule is: NOT EVERYONE is a textbook case, so do not treat them as such. It's critical to develop strong clinical/assessment skills in order to assess progress in labor. It takes time and work, but it's worth it.
    Last edit by SmilingBluEyes on Aug 15, '04
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    I agree with what was said already. I try to keep checks to a minimum but we do also check before pain med.
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    I had no internal examinations at all during the labour and delivery of my last two children (born 12 and 18 years ago respectively in standard labour/delivery wards). My daughter (currently 26 weeks pregnant) has already asked about the policy at the birth unit where she will be delivering and been told that internal exams will only be done in the event that labour is not progressing normally (as determined by other observations).

    I think my daughter is scheduled for one internal examination towards the end of pregnancy (I had only one with each of my last two children), and wonder how many internals are done during pregnancy elsewhere.
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    I had many less internal exams with the midwives for my last two than I did for my first with the dr. This is a nice, informative thread...please keep the answers coming! And, as always Deb..you are a fount of information and once again, I completely agree with everything you have said. I wish you had been one of my L & D nurses!
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    awwwwwwwwwwwwww kim that is a real compliment. Thank you for saying that.
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    You're very welcome and you know I mean every word of it.
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    As usual, Deb wrote the perfect answer. Our facility is the same--the less checks the better. However--we had this one MD (she only does GYN now--thank God!) who would write an order for us to do a SVE Q1hr regardless of ROM. Not surprisingly, many got a fever, baby got tachy and we did a section for distress and she ws home in bed by 11pm. If you did not call her with an update each hour she would hunt you down and then write you up! :angryfire
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    Alot of our docs are too exam-happy for my taste. I try to minimize my vag exams. We have some docs though that will check a pt literally 5 min after you so they can say "she's 7-8" when you said she was 7cm. Ok...and how does that change our paln of care? none.
    Sometimes there are pushy pts and families that want to know every 2 hrs what "she is", even after education on infection, etc. "when you gonna check her again? huh? huh?"
    I love when you have a primip pt with an epidural and they are so worried that the baby is going to fall out in the bed (which yeah has happened, but rare for me) and you explain to them about pressure, etc. Then when they are 10cm they are like "now I know what you were talking about!"


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