Standard of Care Series Part Four
Frequent Vaginal Exams During Labor
In addition to an initial strip on the external fetal monitor (see previous post), often times a vaginal exam is performed upon arriving at the hospital in labor. Vaginal exams provide information for the birth team including dilation, effacement (thinning of the cervix), station, and position of the presenting part of the baby. What this information does not provide is how much longer labor will be. In other words, vaginal exams cannot predict the time of birth. The information provided is a snapshot in time, a progress report, if you will. Every labor is unique, and unfolds in its own way. If myself and three other women went into the hospital in labor and were found to be 4 centimeters dilated upon being admitted, odds are we would not give birth at the same time. Some of us may be mere hours away from birth, while some of us may have a day or more to go. Providing the birthing person and the baby are safe and healthy, time to labor is one of the best gifts we can give birthing people.
Some birthing people like to have the number (how many centimeters dilated) and look to it for motivation in labor. For others, that number can be discouraging or be a source of stress if they are not as dilated as they anticipated. It is also important to note that the information from the vaginal exam may differ depending on who is performing the exam. Having the same person perform the exams whenever possible can help to provide more consistent information. Examine your own feelings about knowing how many centimeters dilated you are in labor, and whether or not that information would be helpful to you. Two questions you can ask yourself and your birth team to help inform your decisions are, “What information will we gain from performing vaginal exams?” and “What will we do with this information?”
An important consideration for vaginal exams in labor is how frequently they are done, particularly if your water has broken. Vaginal exams increase the risk of infection and a possible side effect is rupture of membranes (if your bag of waters has not broken already). If your bag of waters has broken at the start of labor, “the number of vaginal exams you have during labor is one of the most important risk factors for developing an infection called chorioamnionitis” (Dekker, 2019, p 24). This increased risk is often due to bacteria found at the bottom of the vagina getting pushed up towards the cervix as a vaginal exam is performed. “Research has shown that vaginal exams nearly double the number of types of bacteria at the cervix” (Dekker, 2019, p 24).
Whether or not your bag of waters has broken, vaginal exams, particularly in labor, can be uncomfortable or cause stress. Consent should *always* be freely given for *any* vaginal exams performed. A discussion about vaginal exams with your provider in prenatal appointments can help to keep open communication and understanding about the birthing person’s preferences. How frequently vaginal exams are performed may vary depending on your birth place or provider. It is the birthing person’s right to decline any (or even all) vaginal exams including those prenatally and those during labor.
Sometimes, when vaginal exams are performed, the provider may strip the membranes or break the bag of waters without the birthing person’s permission. One way that the birthing person can communicate their preferences during prenatal appointments or labor, if freely consenting to vaginal exams, is to state that consent is given for the vaginal exam, but not for stripping membranes or rupturing the bag of waters if that is not desired by the birthing person. Vaginal exams should *never* be performed without the free, informed consent of the birthing person. This is obstetric violence and abuse, and a violation of the birthing person’s bodily autonomy and rights. How frequently, or whether or not vaginal exams are performed at all, is the birthing person’s decision. Did we mention how consent should *always* be freely given by the birthing person, and that the birthing person has the right to refuse vaginal exams?
The bottom line: Vaginal exams should *never* be performed without the birthing person’s freely given informed consent. Benefits and risks should always be discussed with your birth team and weighed before making any decision. Your individual circumstances, as well as your values, goals and preferences, should be part of the equation. (Refer back to our evidence based care posts for more on this topic.)
Pitocin® Augmentation During Labor
Pitocin®, a synthetic form of the hormone oxytocin, is a drug that can be used as a means of induction and a means to augment labor. For this post, we will be focusing on the latter. Before talking about Pitocin®, it is important to understand the role that the hormone oxytocin plays in labor.
Oxytocin, also known as the love hormone, is what causes the uterus to contract in labor. As labor progresses, the levels of oxytocin created in the brain gradually increase so that levels are at their highest at the time of birth. Oxytocin is released in the bloodstream and the brain during labor. Birthing people sometimes describe experiencing a high or euphoria after the birth of their child, and this is in part due to the high levels of oxytocin. Once the baby is born, oxytocin continues to be produced by the brain causing the contractions that facilitate the birth of the placenta and help the uterus to contract following the birth so that the uterus may shrink back down to its pre-pregnancy size, reducing the chance of postpartum bleeding (a reason why Pitocin® is sometimes used to manage third stage - the birth of the placenta). Oxytocin also reduces stress, anxiety and pain in labor, and prepares the mother to bond, breastfeed and care for her baby after birth.
With this understanding, let’s turn back to the synthetic version of oxytocin, Pitocin®. Pitocin® is administered through an IV into the bloodstream. The amount of Pitocin® is not regulated by the brain, unlike the levels of oxytocin. It does NOT cross the blood-brain barrier, and so the calming effects of the hormone oxytocin are not found with Pitocin®. Because Pitocin® is not regulated by the brain, it may cause contractions that are longer, stronger, or closer together than what the birthing person’s body might produce naturally.
Pitocin® is commonly used to augment, or speed up, a labor that is thought to be taking longer than expected. We could do a whole other post on failure to progress. Early labor, especially for first time mothers, can take many hours. Active labor is considered to be six cm dilated or greater, and the definition of true labor arrest does not include early labor (dilation less than 6 cm). The cliff notes version is that failure to progress may often more accurately be labeled “failure to wait” on the part of the provider. If you’d like to read more about failure to progress and learn about the guidelines for true labor arrest, you can visit Evidence Based Birth®’s article on Friedman’s Curve and Failure to Progress.
So what does the research have to say about Pitocin® for labor augmentation? “Research has shown that when people are in labor spontaneously (meaning they weren’t induced with medication), Pitocin®....may shorten labor by an average of two hours, but not reduce [the] risk of having a Cesarean” (Dekker, 2019, p 23). If the birthing person would prefer to labor as naturally as possible and avoid interventions like Pitocin®, which can interfere with the production of natural oxytocin in the brain and the benefits that come with natural oxytocin, non-pharmacological comfort measures can be used. If the birthing person feels relaxed and safe and supported, oxytocin levels are likely to be higher. This can be achieved by creating a homelike environment at the hospital or birth center, such as low lighting (Christmas lights or LED candles can be a great option for lighting), aromatherapy, music, temperature, etc. Other comfort measures in labor include having a doula (always a great idea!), massage, acupressure, hydrotherapy (immersion in warm water has been shown to reduce the need for Pitocin® among other benefits), changing positions and walking. All of these comfort measures may contribute to oxytocin production and the progression of labor. For example, walking can shorten labor by about one and a half hours, open the inlet of the pelvis, and significantly reduce the risk of having a Cesarean. For more on comfort measures, visit the Evidence Based Birth®’s Pain Management series.
A final note: Pitocin® “is considered a high-alert drug, meaning that there’s a high risk of harm if a health care worker happened to make a mistake while administering the drug. Because of this, Pitocin® should be used with care - only when there is a medical need that outweighs the risks of using it” (Dekker, 2019, p 23). Alternatively, the above non-pharmacological comfort measures have been shown to be beneficial and effective in labor, especially when used in combination with each other, without any adverse side effects.
The bottom line: Pitocin® is not oxytocin. Pitocin® does not cross the blood-brain barrier. Benefits and risks should always be discussed with your birth team and weighed before making any decision. Your individual circumstances, as well as your values, goals and preferences, should be part of the equation. (Refer back to our evidence based care posts for more on this topic.)
You can read more about the difference between oxytocin and Pitocin® here.
Epidural for Pain Management During Labor
Epidurals are a means of administering pain medication during labor to help with pain management. A small needle with a catheter over top of it is placed in the birthing person’s lower back beneath where the spinal cord ends. The needle guides the catheter into the epidural space, and then is removed while the catheter stays in place. Drugs can then be given through the catheter. “Today, more than 60% of people giving birth in the US have either an epidural or a spinal block during labor” (Dekker, 2018).
What are the benefits and risks of epidurals in labor?
Research has shown that epidurals can be a highly effective means of pain management. For example, in a particularly long labor, epidurals can provide the much needed rest the birthing person needs. It may also be an important consideration if the birthing person has crossed over from experiencing pain/discomfort in labor to suffering.
The risks and side effects of epidurals may include a sudden drop in blood pressure for the mother (which may compromise baby’s oxygen levels), headaches (sometimes long lasting), maternal fever, nausea, restricted movement, motor block, difficulty urinating, a higher likelihood of needing forceps/vacuum delivery (which leads to higher risk of severe perineal tearing), higher likelihood of needing Pitocin®, and the potential for a longer labor. Additionally, epidurals come with a bundle of other interventions, something that expecting families are not always aware of. Often with epidurals, continuous fetal monitoring will take place, the birthing person will receive IV fluids, a blood pressure cuff may be used (sometimes left on the birthing person’s arm and then the blood pressure is taken intermittently), a pulse oximeter may be used, and a catheter may be in place to help ensure the bladder is emptied.
If the birthing person does not wish to have an epidural, there are other non-pharmacological comfort measures that may be used. We mentioned a handful of these in our post about Pitocin® augmentation in the context that these non-drug comfort measures often contribute to an increase in the hormone oxytocin. Non-pharmacological comfort measures include creating a calm and home-like birthing environment, having a doula (come back tomorrow for more on this topic), massage, acupressure, hydrotherapy, changing positions, music, aromatherapy, hypnosis, relaxation techniques, breathing, the use of a rebozo, using a TENS unit, childbirth education (hint, hint), and walking. Though more research is needed on non-drug comfort measures, they have been found to be helpful in labor, particularly when used in combination with one another. In addition, non-pharmacological comfort measures often do not have any side effects, and should always be an option for birthing people.
In the American Congress of Obstetricians and Gynecologists (ACOG) Committee Opinion on the Approaches to Limit Interventions During Labor and Birth, it is stated that “when women are observed or admitted for pain or fatigue in latent labor, techniques such as education and support, oral hydration, positions of comfort, and non-pharmacologic pain management techniques such as massage or water immersion may be beneficial” (2017).
The bottom line: Epidurals are a tool in our labor toolkit. Some find they provide the much needed rest to continue to labor and birth vaginally while others prefer to avoid them due to the known risks and side effects. Benefits and risks should always be discussed with your birth team and weighed before making any decision. Your individual circumstances, as well as your values, goals and preferences, should be part of the equation. (Refer back to our evidence based care posts for more on this topic.)
For more information on epidurals and non-drug comfort measures, you can visit Evidence Based Birth®’s Pain Management series.
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*Disclaimer: These posts are not intended to be construed as medical advice and are for educational purposes only. Each pregnancy and labor is unique. If you have questions or concerns, please consult your provider.