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January 31, 2017

Dear OB: it's not your vagina – Part Two

Honoring the imperative of consent

Parenting Motherhood
02032018_pregnant_women_Unsplash Photo by Camila Cordeiro/via Unsplash


“I had a nurse ‘check me’ in the intake area for my last delivery and it was absolutely excruciating! I was literally screaming and crying and she probed around for so long! She told me that they couldn't allow me into the hospital unless I was dilated to 6 [centimeters], so she had to check. It certainly was an awful, awful experience. I did speak with my OB about it and she apologized profusely, saying that some medical providers weren't as gentle as others with cervical checks. When my OB checked me, it was much less painful. I am so glad to know that, in the future, I can refuse these invasive procedures or request to have only my OB check.

~ Emily, mother of two

Mothers-to-be, laboring women, pregnant friends – listen to me.

You have the right to determine who – if anyone – will put his or her hand in your vagina during pregnancy and birth. You have the right to inquire about any procedure that is being suggested as part of your prenatal, labor and delivery care. You have the right to consent. You have the right to request a vaginal exam. And you have the right to refuse one. Period.

Like the women described in "Dear OB: It’s not your vagina, Part One," Emily didn’t know that she had this power – this legal right. Had she known, she may have requested her OB, or a different nurse, check her. Perhaps she would have refused the intake exam altogether. Granted, the hospital staff would have duly noted her refusal, but this might not have troubled the proverbial waters. An experienced care provider could have assessed her stage in labor without putting a hand inside her body.

Emily might have been coerced, cajoled or critiqued for resisting admission protocol. Emily’s refusal may have impacted her insurance coverage. She may have been labeled as going “against medical advice.” Perhaps they would have threatened to refuse care. Nonetheless, contrary to popular opinion, women do give birth in hospital settings without a single vaginal exam, or with minimal exams. This occurs in birth centers and at-home births with even more frequency. For example, Rachel Leavitt, RN, founder of New Beginnings Doula Training, describes what it is like to work at the Babymoon Inn Birth Center in Phoenix, Ariz.:

“We look at a lot of different signs to determine progression. We do very few cervical checks. We use signs such as change in contraction pattern, how the woman is coping, physical signs such as shaking, nausea, bloody show and moaning. You can see how a woman begins to turn inward and the ability to concentrate decreases. These are the typical things we will look for and chart. We only check when women first come in, and if they refuse, we don't worry about it. We will also check if it has been a long time without any external signs of progression or if there is a clinical need. Again, a woman's right to refuse is acknowledged.”

Clearly, birthing women can work in partnership with compassionate, consent-wise care providers. If minimizing your experience of routine vaginal exams is important, it is your right to demand this type of care. It is your right.

For some laboring mothers, the presence of vaginal exams is a benign fact. They are not triggered negatively by the procedure. They may simply assume their care providers know best and regard routine vaginal exams as par for the course. Epidural analgesic certainly makes experiencing difficult exams a moot point.

Ideally, vaginal exams aren’t an issue because laboring women feel they are fully respected and in partnership with their providers. Vaginal exams aren’t something “done to them.” Rather, OBs, midwives and nurses are respectful and obtain – each and every time – the woman’s consent. When exams are administered, they are experienced without pain or with minimal discomfort. Care providers inform women of the benefits and contraindications of checking the dilation and effacement of the cervix. They explain how vaginal exams can help ascertain the presentation, size and position of the infant’s head as it makes its way through the mother’s pelvis. Their providers are able to assess other physiological signs of labor’s progress as well. Such care providers would never think of stripping cervical membranes without explicit and informed consent.

Yet, this ideal is certainly not the reality experienced by many laboring women.

Leavitt notes that legal consent can’t be given if it is coerced, “which happens a lot,” and risks and benefits of vaginal exams should be explained, which “rarely happens,” she said.

It’s hard to confirm her observations with numbers. Few studies have been done with regard to the efficacy of vaginal exams themselves, let alone chronicling women's experiences of such exams. Despite the lack of peer-reviewed data on these points, a great deal of anecdotal evidence exists that many birthing women experience unwanted, painful and routinely mandated vaginal exams. They don’t know they can refuse these procedures and, disturbingly, they are ignored if they revoke consent.

Consider these words from Jennifer, a mother from Ontario, Canada:

“I remember telling them, for at least two of my deliveries, to get their hands out of my vagina. They don't listen. They figure it's the pain talking and if you were in your right mind, of course, you would agree to it. It's easier to refuse in the beginning, when you're clear-headed, but once the pain takes you, they will force your legs open and stick their hand in – whether you're screaming at them or not.”

...Or these words from Michelle, a mother from San Diego, California:

“Fifteen months past my birth experience, and I still think back to repeatedly telling the doctor not to touch me, and she kept pushing down on my perineum, causing me pain. No means no, unless you’re in labor?”

Care providers have their work cut out for them if women walk away from birth feeling violated. We must be willing to question medical practices deemed normative, especially if they do not measure up to the best of evidence-based medicine. Even if we believe routine vaginal exams are an unstated good, care providers are obligated to obtain consent before putting a hand into any vagina. This means women have the right to refuse consent and have this refusal respected. No one should suffer needlessly due to bureaucratic hospital protocols, arrogant practitioners and a shocking disregard for the ethic of consent.

Gale Louise Aucott, CNM, is a founder of Midwifery Care Associates and serves expectant families in Pennsylvania and New Jersey.

She states: “There are certainly situations when [vaginal exams] are of great value. But they should never be forced.”

Aucott served as a clinical preceptor for the University of Pennsylvania’s midwifery education program and draws upon a seven-step method of receiving informed consent called BRAIDED. Commonly used in contraceptive counseling, BRAIDED requires care providers to describe the benefits of a procedure, detail risks, provide alternatives to the procedure and remind the patient that they have the right to inquire further. Furthermore, patients may make the decision to withdraw from the procedure at any time, without penalty. Explanations are to be provided in a format that is understandable and documentation notes that patients understand the six points outlined above.

Respecting birthing women with protocols like BRAIDED is central to sound medical ethics. As doulas, midwives, nurses and OBs, we must safeguard the cornerstone principle of informed consent, central to the honest practice of medicine – central to the ethos of “do no harm.”

After the publication of "Dear OB: It’s not your vagina, Part One," I received the following note from a female resident training in family medicine with a strong focus on obstetrics.

She writes:

After reading your piece I have made an effort to change my language. Instead of saying “I'm going to check your cervix now” I try to say something like “I'd like to check your cervix to monitor how it is dilating and see how your labor is progressing. Is that ok?” And then when I discuss the progress with the RN, I explain to the patient what I'm talking about.

Stephanie Tillman,  CNM, clinical instructor at the University of Illinois at Chicago's nurse-midwifery practice and creator of a popular Facebook page and blog entitled the "Feminist Midwife," concurs.

“I never enter a room and say, ‘It’s time to check your cervix!’” she writes. 

Rather, upon entering a patient’s room, Tillman takes the time to assess the subjective experience of labor from the point of view of the one birthing and any support people who may be in the room. Tillman then explains how she understands the labor to be unfolding from a midwifery standpoint and discusses all options in the plan of care. Should this include a vaginal exam, performed with consent, Tillman conducts one.

Tillman is known for her skill in performing pain-free, or minimally uncomfortable, exams on “difficult” patients – a label she, rightfully, finds offensive. In an effort to strengthen the skill set of her colleagues, Tillman offers a helpful “script” for OBs, nurses and midwives. Step-by-step, she guides them through a vaginal exam, providing suggestions on how best to talk laboring women through the experience. She concludes her script by recommending that care providers ask:

“OK, you’re going to feel me take out my hand. How was that exam? Anything I could do differently next time?”

Anything I could do differently next time?

This is such a respectful question. It affirms that the experience of the laboring mother counts. Perhaps the exam was too rough or fast. It affirms that birth professionals are continually growing in their field and benefit from honest and helpful feedback. Tillman wants to know how a birthing woman experiences a vaginal exam. It matters. Midwifery or obstetrical care shouldn’t be something “done to” anyone. Birthing women partner with the care providers. They don’t discard their power when donning a hospital gown.

Labor involves the dramatic, incredible, often painful and extraordinary emergence of a human being from the body of another. As a birth doula, I’ve been privileged to support women through the stages of labor, delivery and the initial postpartum period. I’ve seen many births. Some of them, I wouldn’t wish on anyone – some of which – were remarkably empowering and sacred events. I also realize that modern medical practice involves a lot of paperwork and data entry. Such compilations of evidence ideally inform best practices. They also constitute a necessary protocol in a hyper-legalistic world.

According to a 2013 Physician’s Weekly report, OB/GYN care providers are the third-most likely medical specialists to be sued. (Perhaps a disregard for the ethic of consent helps explain why.) Far too many procedures, routinely performed in labor and delivery, are justified, due to a fear-based approach to avoiding lawsuits. It’s true. Yet, an outdated, patriarchal attitude that regards a birthing body as something to prod, poke and “manage” sadly persists.

RELATED LINKS: How to decide when to have a second child | Confessed hit-and-run driver tries to apologize to young girl's family | Dear OB, it’s not your vagina

The attitude that deems the private parts of a woman’s body to be fair game (whether sexually or within a medical context) now extends to our Oval Office and it is patently offensive. We need a feminist-based, compassionate, and ethical approach to obstetrics and gynecology. Not only is this best for mother and child, it is what birth workers are morally and legally required to provide.

Finally, there is a debate to be had with regard to best care practices regarding routine vaginal exams during labor and delivery. Consider this 2013 overview of two studies conducted in the 1990s examining the efficacy of vaginal exams in improving maternity outcomes. The authors of the overview acknowledge that vaginal exams are sensitive procedures. They are also surprised by their widespread use.

More studies are needed. And whether or not future studies prove that routine vaginal exams improve outcomes, consent is key. It must be sought, obtained and respected.

I requested minimal vaginal exams during the birth of my son. I had seen far too many painful vaginal exams done as a doula. I had held far too many hands of laboring mothers as they cried (or screamed) while an OB, nurse or midwife performed a rough exam, sometimes stripping membranes, without consent, along the way. I had absolutely no interest in subjecting myself to this fate. My midwives were extremely skilled, intelligent, kind, gentle and firmly aware of their responsibility to obtain my consent for any procedure. If they believed a vaginal exam was in order, they explained why. None of their exams hurt. They were spaced many hours apart. My midwives relied on a wide variety of assessment tools to safeguard both my safety and the safety of my soon-to-be-born son. I trusted my care providers. They always explained benefits and risks. They always obtained permission. I felt respected because I was respected.

All birthing women deserve to be treated with such respect. Care providers are legally and morally obligated to extend the ethics of informed consent to birthing women with regard to routine vaginal exams. All birthing women deserve to have their human integrity, autonomy and dignity respected. Should providers fail, it is up to birthing women to demand their rights.

Yes, demand them.

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