Dear Henci,

My name is Brian and I'm representing my wife Heather who is at home recovering from a c-section. 

This was her first pregnancy and she had expected a natural birth until her membranes ruptured about three weeks before her due date.   Regular contractions started about an hour later and we went to the hospital.  A few hours later and she was on pitosin.  Then about six hours later the nurse discovered that the baby was breech.  We were told that there was no choice but to do a c-section.

Naturally, we were overjoyed to see our new son, but as the days went on we began to wonder what caused her membranes to rupture prematurely.    We had put so much effort into this (our first) pregnancy only to get less than satisfactory results.  Sadly, our doctor informed us that it would be next to impossible to uncover a cause for her premature rupture of the membranes (PROM).  

So without a definite cause we turned to statistics for answers.  And we didn't like what we found.

Some studies claimed that internal exams, done during the 9th month, can increase the risk of PROM, and some studies found  this to not be the case.  But I couldn't find a study that demonstrated the usefullness of internal exams. 

So why did our OBGYN conduct an internal exam?

Here are the details.  During the 36th or 37th week we went in to see the doctor and were told that it was time to "check the cervix".  This sounded benign enough so my wife got into her gown and let the doctor peek inside.  But the doctor did more than peek.  She swabbed her cervix and then (with a glove) felt around for about thirty seconds.  My wife was in pain the whole time.  Then the doctor informed us that bleeding and discharge would be normal within the next five or six days.  We were shocked!  Dumbfounded, we left the building but the reality hit us a few hours later.  The natural pregnancy was over.  We felt violated, angry, and sad.  

Six days later, her waters broke prematurely.  Admitedly, there's no way to know if the internal exam played a role in this, but it's unsettling to think that our doctor may have increased the risk of PROM without our consent.  In fact, our doctor didn't tell us anything more than, "now I'm going to check the cervix".

I've come across various risk factors for PROM and the only three that we had were: Baby found breech, Group B Strep found on the cervix, and the Internal Exam. 

note: the internal exam found her cervix to be at zero

I'm not even sure if the above mentioned are actually risk factors or not.  I was hoping that the Ask Henci Forum could somehow shed some light on the situation. 

Did our doctor break the law by not getting informed consent?  Why did it take thirty seconds to "check the cervix"?  Why was there pain?  Why is bleeding and discharge considered normal?  Why is there such a high rate of PROM?  Why did we constantly feel on the defensive in our doctors office? 

Any information that you could share would be great.

Thanks for providing such a nice forum.

-Brian Heather, and baby Henry

It has become routine to check the cervix every week once a pregnant woman reaches full term (37-42 weeks pregnancy duration). As you have found, some research suggests that the examination may increase the risk of prelabor rupture of membranes. More importantly, NO research has found that the practice has any benefits. The information gained from this exam has little predictive value. A woman can have a soft cervix that is completely effaced (gathered up into the uterus--think of pulling your pursed lips flat) and starting to open, and the baby's head can be low in the pelvis, and she can go for another couple of weeks before labor starts. She can also be "none of the above" and go into labor the next day. On occasion, it is useful to evaluate readiness for labor when an induction is under consideration, but the general rule is "don't have a test unless the information will be used to make a decision."

Unfortunately, as you have begun to discover, virtually all obstetric tests, procedures, and restrictions have been shown to be harmful, ineffective, and usually both when used routinely or frequently and sometimes with any use at all. This is because any intervention in the normal process has the potential to cause harm, so when it is imposed in situations where there is no problem or a problem that could be solved by lesser means or just by having patience, there is no counterbalancing benefit.

Your doctor did not break the law because your wife accepted the exam, which is implied consent. I don't think it would occur to any doctor to ask specific permission in that a vaginal exam would seem to their minds to be as trivial and innocuous as taking your wife's blood pressure or listening to her heart. Of course, for a woman with sexual abuse or assault in her past, this might be far from the case, apart from any possible adverse effects or discomforts of the exam, but that is an argument for another day. I don't know why the exam took such a long time or why it was so uncomfortable. You could ask your wife's ob this, although it is likely the ob won't remember.

I don't know if the rupture of membranes a week later is connected. In any case, with so few doctors doing vaginal breeches, your wife would almost certainly have had a cesarean anyway. The only way that might have been averted was if your ob had told you the baby was breech, which can often be discerned by feeling the baby's position from the outside (Leopold's maneuvers), although it is not foolproof. Now's there's a test with real value! It has no downside, and if you had known in time, there are things that can be done to try and get a breech turned before labor. 

If your wife finds she is experiencing emotional distress over this birth, I recommend Solace for Mothers, a website that offers peer support for women who have had challenging childbirths. You may also find peer support and information on cesareans and vaginal birth after cesarean (VBAC) on the International Cesarean Awareness Network website.  And you can give feedback on your care provider and hospital on the Birth Survey website, which will help other women make informed choices of care providers and place of birth.

-- Henci

I did a quick search and couldn't find the link, but I remember reading that for each vaginal exam, doctors charge insurance companies $200.00.  (Don't quote me on this until I can find the source).  That may not sound like a lot compared to the many more lucrative obstetric tests and interventions.  But it adds up if you're an OB seeing, say, 5 term-pregnant patients in one day...and who knows how many in one week!

I'm mentioning this because it may explain why routine vaginal exams persist despite there being no evidence to support the practice.  Perhaps the original poster's wife simply became one of countless victims of our country's absurd profit-driven, fee-for-service health care "system."  Forgive the rant. 

If you find that source, please let me know. I would like to have it for my files. While most childbirth reformers understand the degree to which fear of malpractice suits drive care, few are aware of the extent to which profit drives care. The new edition of Obstetric Myths Vs. Research Realities will discuss this. (Did you know, for example, that obs who were major holders in the company manufacturing EFM equipment conducted studies of continuous electronic fetal monitoring, promoted its use heavily, and then went around the country giving expert testimony in lawsuits that EFM could have averted neurologic injury?) You might also like to read a great article Susan Hodges wrote after she and I gave a talk together some years ago at a CIMS conference entitled "Economic Disincentives for Mother-Friendly Care." 

-- Henci