Wednesday, August 26, 2009

Vaginal Exams

I was on call recently and had a woman attempting a VBAC. She had gotten an epidural and so I went to lie down for a bit. I slept almost two hours then got up to go check on her and my other patient. In a three hour period, my patient had been checked 6....yes, 6 times by the nurse! And she was ruptured! I asked the nurse why she felt the need to check the patient 6 times in a three hour period and she told me she did it because the patient would ask! Give me a break! It's her first baby vaginally....it won't fall out (and if it does - great, that's the point!). We were assured of her progress. There was nothing on the strip indicating the need for a vaginal exam. Are you fer real????

I rarely ever do that many vaginal exams in a woman's entire labor!!!!

There is research that shows after the fifth exam (one membranes are ruptured), a dramatic increase in the risk of infection. So keep your damn fingers out of there please!

Some nurses are really good about this but others drive me nuts. I have written as an order, no vaginal exams without checking with me first. I just can't always rely on the nurses' judgement as to when a vag exam might be appropriate. Really, some of these nurses have been doing this as long as I have been alive. You really ought to be able to look at a patient and tell a lot about where she's at based on how she behaves, what she says, etc. If the patient is smiling and laughing during a contraction and is ruptured...I don't care if she's a grand multip...it's not likely to fall out - don't check her!

I was always taught that you should only do a vag exam if it will change your managment. I try very hard to stick to that, I think it's a great rule!

8 comments:

Beetus said...

The nurse could check her six times or she could have 1) educated her about the risk of infection from frequent vag exams 2) encouraged her to sleep to increase her chances of a successful vbac or 3) did some teaching about how the baby won't just fall out!!!!

If the patient has asked you to check her every 1/2 hour and you, as the nurse, do so, not only do you have no clue how to base your care on best evidence, you have no ability to teach or manage your patients expectations.

And you're absolutely right, a good nurse does not need a vaginal exam to tell if their patient is close to complete. Pressure, quality or amount of show, change in maternal behavior, changes in fetal strip,etc. Many, many clues are available.

minority midwife said...

Whoa! Wooooow. Sigh.

I was also taught the "will it change your management?" rule and it has really helped me with decision making!

Anonymous said...

My last birth the nurse checked me every 20 mintues. I was in the hospital 5 hours before the birth. Five hours. Some times she held back my cervix druring two contractions. It was horrible. I had birthed 5 babies before and she was stretching my vagina with oil. What the? I felt sooo violated but didn't utter a word but, "ouch, that hurts." I didn't realize she was checking me regularly until she said she was trying to do it every 20 mintues. I have had so many babies and vaginal exams, but that time I felt soooo strange, and felt truly violated. Of course, it took about a day to realize what the sick feeling was, and then I did. I felt sexually invaded, really. She also had me flat on my back for these and I had one big bad decel in the first hour causing everyone to freak and keep me in bed. Every time she had me lay back (why I didn't fight I cannot explain, I wanted to)...I worried about decels. It was truly horrible. On top of that I had OB's doing cervical exams too. I am so blessed the bag didn't break and baby was born in the caul!

Blessings!
Dawn

Joy said...

Even I know that's too much! I don't expect any except one upon arrival and when I feel that urge to push (they always check to make sure I'm fully complete).

Ciarin said...

Wow Dawn, I am speechless! What an awful experience. I'm very sorry that happened.

Anonymous said...

I have had 5 babies before that one, and yes, never had very many exams before. Never had anyone stretch my cervix or perinium, but this woman did. Also, I did have the "good patient syndrome" because when my baby had the first decel...80bpm that wouldn't change on my left side I rebelled and sat up. That was in the first half hour, I was begging to get in the shower and she said, "I just need to check you" and then baby had a decel. After that she restricted me and I complied. The OB came in and said, "I'm pretty liberal but baby's heart rate isn't variable enough to let you out of the bed..." but eventually OB did say I could get out of the bed but had to leave the IV in. Nursie let that happen for a while, but then kept insisting because of the dumb monitor. I didn't fight, and I didn't want to fight. I was having back labor since baby was OP. Even another nurse argued with this nurse toward the end a small bit because she wanted to put in a scalp monitor, and doc (different one after shift change) said he wouldn't break my water....the nurse reminded her of it. She insited, but because I was able to move finally per OB order, I had the baby before he got back to the room....

This time I will be using a different doctor or a midwife from a completely different group because I think the docs stayed out of the room too much. Also, I am going to ask for a very experienced nurse who is not afraid of natural birth and catching babies. I think only an exam every 4 hours is needed, or less...

Dawn

Blessings!
Dawn

pinky said...

I was taught you should only check someone if you need that information to make a decision.

Anonymous said...

I am a student nurse and am currently doing my rotation through OB. I did my first vaginal exam on a patient with the encouragement of my preceptor nurse and consent of the patient. After, my exam the preceptor did one so we could compare dilatation. The nurse was much more vigorous than I and ruptured her membranes. I asked then nurse if we would then decrease the interval of vaginal exams (from 2hrs) and she said no. What??! Needless to say, I didn't do anymore exams on this mom and I totally agree with you, Ms. Midwife. I when I grow up to be a nurse, I will take this with me, even if OB isn't my final destination.