Internal Examination during labour

Health warning - If you're not interested in reading about things that happen during labour, this particular blog post probably isn't for you. I promise to make the next one more inclusive for everyone!!

This blog post is taken from an article available here... http://sarahvine.wordpress.com/2010/03/07/how-dilated-am-i-assessing-dilation-without-an-internal-exam/

I think its fascinating and had to share it with those of you who are interested in it. I don't feel comfortable with the idea of internal examination, as I think its counter-inductive to the labour process. Plus, I don't really want to know how dilated I am, as it might have a negative impact on me psychologically if I discover I'm not as far along as I thought. This has been an issue of particular contention between my midwife and I as she would prefer to examine me at least once to see how things are going and I feel that by her wanting to do this, she is missing the point of how I view labour and the process of birth. At the end of the day, she can't do anything without my consent, but I don't want to have to discuss this with her on the day when I'm trying to keep myself calm and relaxed. I plan to show her this article, so if she is still determined to know the condition of my cervix and how far along we are, she can still do it, without having to put any gloves on!!

How Dilated Am I? Assessing Dilation in Labor WITHOUT an Internal Exam.

7 March 2010 by sarahvine

It’s the magic question weighing on most laboring mothers’ minds: (as well as the minds of her partner or birth attendants!) How much longer? Is there any way to tell how far along I am in the birthing process? I’ve seen mothers beg for an internal exam and then be gutted about the answer (What? ONLY 4cm STILL!?) and suddenly *poof* she looses her resolve. It’s akin to having a test and finding out you’ve failed it, in front of your loved ones as well as complete strangers. Everyone knows this feeling is not conducive to labor – suddenly doubt and fear slide in and the laboring mother feels tense. Her oxytocin levels (our body’s natural pain-killer and labor inducer) take a nose dive and immediately she feels much more pain and she starts to run away from the contractions.

Happily, there are a number of external cues that can help you and birth partners get clued in to how much labor is advancing. Some are more subtle than others, but if you are ignoring the clock and keeping focused on staying in tune with your body, you will see them. Listen, embrace, wait. Enjoy the way it responds! It is amazing what it can do, this body that God gave you.

1. Sound. The way you talk changes from stage to stage in labor. With the first contractions, you can speak during them if you try, or if something surprises you, or if someone says something you strongly disagree with. You may be getting into breathing and moving and ignoring people – but if you really want to you can raise your head and speak in a normal voice. When the contraction disappears you can chat and laugh at people’s jokes and move about getting preparations done. During established labor, There is very little you can do to speak during a contraction. You feel like resting in between, you are not bothered what people are doing around you. As you near transition and birth, you seem to go to ‘another’ level of awareness – it’s almost like a spiritual hideaway. You may share this with someone else, staring into their eyes with each surge, or you may close them and go into yourself. In between surges you stay in this place. It is imperative for birth assistants and partners to stay quiet and support the sanctity of this space: there are no more jokes, and should be as little small talk as possible. Suddenly, the sounds start to change involuntarily: you may have been vocalizing before (moaning, talking and expressing your discomfort, singing, etc) or you may have been silent. Listen – there are deep gutteral sounds along with everything you have heard before, just slipping in there. You are about to start pushing.

2. Smell. There is a smell to birth, that hits towards the end of dilation, during intense labor, just before birth. It is a cross between mown hay and semen and dampness. It has a fresh, yet enclosed quality, and is pervasive. The Navelgazing Midwife has also observed this scent and writes about it here.

3. Irrationality. I love this clue – it often is a sign of transition. It always makes me smile, and I always warn women about this phenomenon so that when we hit it during labor I can remind them that what they’ve just said is irrational, and that I told her this would happen, and here it is! Relax, it means we’re nearing the end. Sometimes a mother will say she wants to go home, she is done now she’ll come back and do this later, she wants to put on her trousers and coat and go out the door. A mother who wants a natural birth and has been coping brilliantly will suddenly say she was crazy and needs pain killers right now, or that she didn’t want another baby anyways, who said they wanted a baby? Some will just curl up and say they’re going to sleep now. If she does this, that’s okay. The contractions may die down, get farther apart, and maybe she (and the baby) will get a few minutes of sleep. This slowed down transition sometimes freaks out doctors or hospital midwives and pitocin is offered – try to see if you can put them off for half an hour. Send every one out, lie on your left side propped up by pillows and have a little nap before pushing; it is such a wonderful gift.

4. Feel. Here come some of the more fun tools that you might not have heard of before! Think about the shape of the uterus. Before labor, the muscle of the uterus is thick evenly around all sides, above, below, behind. As the cervix starts thinning and dilating, all that muscle has to go somewhere – it bunches up at that top. The top of the uterus thickens dramatically the more the cervix opens. During a contraction, at the beginning of labor, check how many fingers you can fit between the fundus (top of your bump) and the bra line – you will be able to fit 5 fingers. As the top of the fundus rises higher during labor, you will fit fewer and fewer fingers. When you can fit 3 fingers, I usually tell mothers they can think about going into hospital as they will find they are around 5cm dilated. At 1 finger, you are fully dilated. (Awesome, huh! Here is a blog post by a woman who describes in great detail checking her own cervix just before she went into labor.)

5. Look. There is something called the ‘bottom line’, which is shadow that extends from the anus up towards the back along the crease of the buttocks. It begins as 1cm and lengthens to 10cm, and it’s length correlates with cervical dilation. Why not look down there before inviting a stranger to put their fingers up inside you? It makes sense to me.

6. Gooey Stuff. Also known as bloody show; there is usually one at around 2-3 cm dilation, and it can happen during the beginning of labor or a few days before hand. Sometimes it’s hard to know what is or isn’t a show, since during the days before labor the amount of vaginal mucus increases in preparation and this can be confusing. A show is up to a couple of tablespoons in quantity, so quite a lot. It can be clear, but is usually streaked with pink, brown, or bright blood. If there is more than a couple of tablespoons of blood then you do need to go straight into hospital to make sure the placenta is not detaching, but if there is just a bit and then it stops, then it is just show. There is a SECOND show at around 8cm dilation. This second show means that birth is near.

7. Opening of the Back. This is just at the spot where your birth partner has been doing lower back massage, at the area above the tailbone. It is a little smaller than palm sized, rather triangular-shaped area that bulges out during pushing. At this point you’ve waited too long to go into hospital, and you need to refer to my last post, 4 rules of what to do when delivering a baby!

8. Check yourself. Okay, so technically this one is an internal check, but it done by YOU. You don’t have to announce the results or write them down: it is not an exam. To me it’s obvious that as the owner of your body, you have more of a right than anyone else to feel comfortable with it and understand how it works. It is best to get to know what your own cervix feels like from early on in your pregnancy, if not before, and then to keep a regular check on what feels normal. If you do this through out your pregnancy you will keep your flexibility into the 9th month. This is also an excellent time to remind you to not neglect perineal massage since you’re already down there! Check out the website My Beautiful Cervix to see photos and descriptions of what a cervix should feel like. At 1 cm you can fit the tip of one finger inside. Use a ruler to practice discerning how many centimeters dilation feels like, measuring with your pointer and middle finger. NOTE: Always, always, always wash your hands thoroughly beforehand, up to the elbows, for 4 minutes at least. Do not assess your own dilation after your waters have gone.

For more labor tips and information about external assessment of dilation, I recommend finding a copy of Anada Lowe’s book, The Doula Guide to Birth, Secrets Every Pregnant Woman Should Know. This is one book packed with practical and useful information!

Can i stop working now please?

Its official - I have hit the wall. The motivated streak I seem to have been on is definitely running out of steam and is being replaced by a general feeling of being fed up. I'm struggling to stay awake during the day for long enough to actually get any work done - I seem to be writing in 20-30minute bursts and then I have to go and get some fresh air to wake myself up, or have a nap because I can't keep my eyes open. I think I'm stalling a bit because I know that once I've got this little bit of work done and sent to my supervisors, the next thing that will be happening is the birth (assuming baby doesn't come early) and thats apparently causing a bit of a mental block for me. I'm excited about having the baby and the birth and everything, but subconsciously I know that once this stage of work is over, theres nothing to stop me going into labour. Its a bit like when old people know they are going to die, and they can hold on long enough to get all their affairs in order and say their goodbyes and then once they've done that, they let go. I think I'm having the same thing, where I know that once I send this work off, I can relax and let go and have the baby but I know I need just that little bit more time.

The insomnia that my heartburn/backpain/general difficulty sleeping is causing is really starting to have a detrimental affect on my work, as I seem to need to nap all the time, and if I don't, I get a headache. I literally want to sleep all the time and I put off getting out of bed longer and longer in the morning so I can at least feel like I've had a good amount of sleep. It takes me ages to get to sleep and then I wake up a lot of times in the night because I'm uncomfortable, or because I've got heartburn or He's elbowed me in the back of the head or something. At least I'll be used to no sleep when the baby arrives!

We decided on our pushchair this week and my dad has ordered it for us. We also went to look at baby things over the weekend and his mum has decided she will buy us a crib for the baby. We were going to get a moses basket and then a cot, which she'd offered to get, but we realised that a little rocking crib would be just as good, if not better because we can keep the baby in it for a few months longer than we could with a moses basket and then we can have it in the cot bed she has kept from her youngest son. We found a really nice white one in Mamas and Papas and we've found a lovely bumper and blanket set to go with it. I'm so excited about the crib and the pushchair arriving at the house and being set up as it'll make me feel like we're actually ready for the baby to be here. We've got almost everything that we will need for the fist couple of weeks now and if we realise we've not got something, He can easily go and get it, or we can ask one of our parents to. As long as the baby has clothes, nappies and somewhere to sleep we'll be fine.

He's been amazing over the last few weeks and has made it really clear to me that he's excited about the baby and ready for it to arrive. I keep hearing him talking really positively to his friends about having a home birth and the hypnobirthing techniques I'm using and how he understands everything I've been saying about medical interventions making things worse for me and the baby. It's so lovely hearing him talk about it in as passionate a way as I do rather than just saying 'oh she wants to do this stupid thing that I think is a massive waste of time' which I know is what he thought o begin with before he really engaged with it and understood everything I was saying to him. Things have much much better with us recently too. He's more enjoyable to be around and is making an effort to help out with things around the house. I've been much more relaxed and less uptight about things in the past few months which has really helped as we're not both constantly annoyed at each other all the time. I make sure that I let him know when he's said or done something that I appreciate and that has made me feel good about him and us and whats happening and he's even started saying nice things about how good I look which he would never do, even before I fell pregnant. It sounds a bit soppy but we seem to have fallen in love with each other again and it's wonderful. 6 months ago I thought this pregnancy was going to tear us apart because we both responded so differently to it to begin with but now I think its done the opposite and has really brought us together as a couple and as a family. I hope it continues once the baby arrives - I'm sure it will do. The last few weeks have taught me that I need to have a little bit more faith in him because if thats been anything to go by, he's going to really surprise me after the birth and I can't wait :)

Teachers pet

I am absolutely loving uni at the moment. Things have really fallen into place this year with the project and my supervisors and my mentality towards doing the work - it couldn't be going any better and I'm so pleased!

I've been working really hard to get everything I would need to do in my first year completed ahead of schedule in order to be able to take 2-3 months after the baby is born, before gradually working back up to full time by september/october. In order to do that, the plan is to have my first year upgrade document, which is submitted in may, written to a decent standard by the time I go on maternity leave. We've arranged supervision for the 21st february and that will be the point at which we stop and allow me to have a bit of time to myself before the baby is born (assuming it's not arrived by then!) So if the upgrade document is ready for then, it means I will be 4 months ahead of schedule -and my supervisor basically said that over the summer, no-ones really expected to do that much anyway, so it's not as if I'd be falling behind or anything. Getting the upgrade document done means that I won't need to take an official suspension period, because if I do, the funding I get stops, and we can't afford to not have that income. Even if we're not really spending it, it means we can live comfortably without having to worry about bills etc as it'll all be taken care of and we can concentrate on enjoying those precious first few months with our new baby.

My supervisors are thrilled with what I've been producing - the policy review I sent to them last week is pretty much perfect, so they've said now the task is to pull the policy review and the brokering review together in order to develop my research questions and start to really direct the project. We've decided that I will work alongside him and a couple of other researchers on a project looking at discharge and re-admittance of elderly patients because it means I can be written in to the ethics approval (which makes my life easier) and I can share data with the other people involved (again making my life easier). I will be responsible for looking at knowledge brokering within the process so will be able to co-ordinate any papers written on that, and write sections for other peoples papers. Justin said it also means that we can switch roles for a few months, where i'm doing the conceptualising and thinking things through, while he does all the leg work to get everything put in place ready for me when I return full time in october for the data collection phase.

I am so happy it's all coming together so well and really pleased that we can now see an end point for me - having something fixed to work to is really good for my focus and motivation, especially with the due date getting nearer and nearer. It's important for me to see a point at which I'm comfortable to stop and where I will easily be able to pick things up again once my brain, and the baby, will let me. Everyone thought I was being really ambitious at the start of october when I said that I was going to get everything done by the end of february and I wasn't going to suspend my studies because I didn't think I would need too. People really doubted that I'd be able to really get going on the phd because of my pregnancy and the impact that might have - but I was so determined to make it work and if anything I was driven even more by people doubt and I hope those people now realise that they shouldn't have doubted me because I can achieve things, often against the odds. Anyone who really knows me, knows that I'm driven and motivated and when I say I'm going to do something, I mean it. I worked so hard to get on the PhD course that I was never going to let anything stand in the way of that. I've been very lucky that my pregnancy has been smooth enough to allow me to work as efficiently as I have, and hopefully that will continue in the next few weeks and once the baby is born. Of course, I am prepared for the babys arrival to completely change everything, but in the meantime, I plan to continue working hard to get my upgrade document done, because thats what I set out to do at the start of they year and thats what I need to do so I can relax and not worry about uni once the baby is here.

Yesterday was my 24th birthday. I would never in a million years have dreamed that I would be on the verge of being a mum on my 24th birthday - 34th maybe - but not now. I had a lovely relaxing day with Him - we spent the afternoon at his mums & she did an amazing roast dinner & he made the most incredible chocolate fudge cake. I had lots of kind messages from friends and family, and really enjoyed just spending time with people I care about and not having to do the whole going-out-drinking thing that usually dictates whether you have a good birthday or not. In previous years when I've organised things they've been a disappointment, or I've not been well, or theres been exams at that time and people can't com, so this year it was good to not worry about organising anything and to just have a good day. Unfortunately, as the day progressed, I did develop a pretty nasty cold which mum had last week and I must have picked up from her. I'm so used to reaching for the lemsip and the ibuprofen when I'm ill that it was really strange not to - you can only have paracetamol during pregnancy - so I've been taking that, eating lots of throat sweets and trying to up my vitamin C intake with lots of fruit. I'm currently eating a bowl of watermelon and grapes - I can't have citrus because it makes my heartburn unbearable and quite often makes me sick too. I had a hot water bottle last night to soothe my aching muscles and went to bed at 8.30pm to try and sleep off the worst of it. I'm feeling better today, and am really uplifted by such a positive meeting with my supervisors.

I'm going to spend the day chilling out and looking after myself and probably tomorrow too. Mum and Steve go to Sri Lanka for 2 weeks on weds and I'm house/dog sitting so will do lots of work on my upgrade document while they are away. Staying there is really good for doing work because theres less distractions, and its good for me in general as I can eat well and get lots of fresh air when taking the dog out. I could probably get most of my upgrade document written while I'm there to be honest, as theres no reading that needs doing really, its just pulling everything together and making something coherent from it. I'll probably be able to start writing my methods section too, depending on what I decide my research questions are going to be - after all the more I can get done now before the baby comes, the better for me in the long run!

EastEnders

A TV soap is not something I would usually blog about but since they've been doing this cot -death/baby switch story line I've had so many people asking me about it and if I've been watching or just avoiding the whole thing. I think they're expecting me to say how awful I think it is and how I've been sobbing while watching, or that I've switched off in disgust and made official complaints etc - so I've decided to blog about it as it's clearly something people want to talk about.

For those of you who haven't watched it, heres a brief summary of whats been happening (bear in mind, Eastenders made it clear a few months ago that this would be the big christmas/new year storyline so we were all warned about it)....

Kat and Ronnie both delivered baby boys on the same day. Kat had her family with her and named her baby Tommy. Ronnies husband Jack was struggling to get a flight home so missed the birth of his son, James. The next day, it's new years eve. Everyone is the Vic partying apart from Ronnie who is at home with baby James and Kat who is in hospital following a bleed as her placenta had separated - so Kat has hardly spent any time with her baby. Ronnie wakes from a nap and discovers baby James has died. She picks him up, tires to find her phone but can't, bangs on the neighbours doors for help but they are all at the Vic so no-one answers. She makes her way over to the pub, holding her dead baby and after hearing baby Tommy crying, finds herself in the nursery with him. Tommy is alone, as everyone is downstairs in the pub bringing in the new year.

The episode ends here and begins with Ronnie walking back to her flat holding a baby to her chest, as she did in the previous episode. We later learn that she has switched the babies - remember she is in shock at the death of her own child (after having a miscarriage earlier in the year and discovering her long lost daughter only to have her die in her arms) and it is made cleat later in the episode when Ronnie realises what she has done and tries to take baby Tommy over to the Vic. On her way over, Jack returns home and takes 'his son' into his arms, as we hear Kat screaming as she returns from hospital to discover her baby has died. Ronnie has got caught in a situation she cannot get out of.

In the following episodes, as Kat and Alfie grieve for their baby, Ronnie struggles with the guilt of what she has done, refusing to breast feed 'James' or allow anyone near him. She doesn't leave the house for several days and everyone is worried about her. The health visitor notices there is no sign of the club foot reported in James' discharge notes but shrugs it off as a mistake. Ronnie manages to say the words 'it's Tommy' to her sister Roxy, but Roxy assumes that Ronnie is just having a lot of anxiety over what has happened to baby Tommy and tries to calm her fears.

So that's where we are. Ronnie has a baby which isn't hers, though she didn't consciously switch the babies, and Kat is mourning the loss of her child, instinctively knowing that something doesn't add up. The BBC has received nearly 4,000 complaints over the storyline, with people on social networking sites reporting their disgust at how the story has been handled and how insensitive it is to people who have lost babies to SIDS.

Now, forgive me for getting a bit ranty here, but

1. IT'S A SOAP - its not real life

2. we knew this was going to happen, so if it's effected you/someone you know then don't watch it

3. should soaps stop having characters die, or be raped, or whatever else just because it might upset someone?

If the storyline had involved Ronnie deliberately swapping the babies in a pre-meditated way then yes, I could understand people getting so upset over it, but the writers have done it in a way to demonstrate the mad things that people do when they're in shock/grieving/mega hormonal after birth/have gone through all the traumatic things Ronnie has. The whole point of it is that she does it without realising and then gets caught in a snowball unable to get out of the situation - and we can see she's trying. She tried to return the baby and she tried to tell Roxy. The actress playing Ronnie is reportedly leaving the soap later this year as she felt uncomfortable with the storyline, and many of the writers and actors involved also felt uncomfortable. We'll I'm sorry but aren't soaps there to cover stories of this nature. They're not sensationalising anything, they're not making out to be a glamorous and wonderful thing, they're raising awareness of a difficult issue which is what soaps are renound for doing. Everytime a soap does something a bit challenging, they are either commended for bringing into the public awareness or they are vindicated for 'doing it wrong'.

With all the awful things going on in our country and all around the world, have people really got nothing better to do than moan about FICTIONAL characters involved in FICTIONAL storylines in a TV soap. We should all get a grip.

Oh, and for the record, no I do not find it upsetting because it's not real. It's a drama. It's meant to be dramatic and have some grasp on reality but it doesn't mean I'm going to sit at home clutching my bump and crying into a babygrow and then become a super paranoid over protective mother just incase some crazy grieving lady swaps her dead baby with mine. NO because I can detatch what I watch on television from goes on in my own life and if I did get completely freaked out and distressed by it, then I'd like the men in white coats from the funny farm to take me away please. I'm not saying that SIDS isn't an awful thing and yes I'd be heartbroken if it happened to me, but I'd also be heartbroken if my partner died in a tram crash like on Corrie, or in a fire like on Hollyoaks, or if I was framed for murder like on Emmerdale. It doesn't mean that I'm going to watch these things happening and assume it will happen to me. If we all reacted like to the things we see on TV and in films the world would cease to function, so people, get a grip, stop moaning and turn it off if you don't like it. No-one is forcing you to watch it after all!!

... and a new one just begun

2011. The year I become a mother and my life changes forever... and I'm SO EXCITED!!

New year was pretty quiet for us. We spent the evening in together as I couldn't really go out anywhere and He wasn't particularly in the mood, so we cooked dinner and watched the telly together. I actually got a bit grumpy and went to bed early coz my back and hips were hurting so much and I couldn't get a grip on my heartburn at all. I'm definitely at the stage of pregnancy where getting comfortable at any time of the day is really very difficult. My favourite thing at the moment is the way my whole pelvis cracks when I move in any way which involves my bum.

Bump is getting even bigger, more so than it was last week....

I love it though :) At the weekend I'll be 32 weeks pregnant and it will be my 24th birthday, which I'm not al that fussed about to be honest. I'm just counting down to 37 weeks because then we'll be allowed to have our home birth, so just 5 and a bit weeks to go. I saw the midwife on tuesday and we've made an appointment for her to do a home visit at 34 weeks so we can talk through my birth plan, and she can assess that the house is ok and suss out what we've got and what we will need. Once I've had the all clear from that appointment that a home birth is going to be ok for us, I'll order my birth pool :-) VERY EXCITED, it's all getting a bit real now, but I'm not scared, or worried I'm just looking forward to the experience of labour and meeting my baby :)

He is in Nice with the boys from work this week. I'm missing him but I'm loving having the house to myself so I can clean and do nesting baby things without him getting freaked out by it. I'm not distracted by his mess so I can concentrate on doing my uni work -I've done so much this week and I've had time to write my proper birth plan too. I'll post it up one day, so anyone else who wants to have a natural birth can use it to guide their own. I've also been reading 'Childbirth without fear' by Grantly Dick-Read which is just wonderful, even though it was written in the 1940's. I wish it had made more of an impact on medicine and midwifery when it was published because it really sets the tone for everything that natural birth holds to be important. Every pregnant woman should be given a copy at her first appointment with the midwife as its just wonderful and would really open peoples eyes to what birth can and should be like - I'm sure many of my future blogs will have quotes and paragraphs from it!