It was much easier the second time around as I found myself much more quickly. My first labour was 29 hours long and I think much of that was because I held myself up whenever I lost focus. My second labour was 8 or 9 hours and I felt much more focused and relaxed. I found framing the experience on my own terms made the difference.

I can’t tell you want will work for her come this September. Pain killers may help her frame the experience. But for me they only would have induced panic as I was on drugs during my ordeal. The last thing I wanted during labour was drugs to dull my senses.

I’d been through counseling years before my husband and I got pregnant and I thought that my issues with the abuse were resolved. However, when I was about 36 weeks pregnant with my older son, I ended up in the hospital in early labor. Unfortunately, I had a nurse who was rude and who did a vaginal exam without even introducing herself. I had a normally progressing pattern of contractions, but when the nurse did this I felt very powerless and my body went in to “fight or flight” mode. I don’t understand all of the biochemistry, but my contractions stopped completely for about a week. During that time, I shared the concern with my OB that memories and feelings of the abuse and been triggered by the nurse. Her only suggestion was to get an epidural.

When I went into labor a week later, I was hoping to have a natural childbirth. But as things became more painful I felt like everyone I was supposed to trust doubted my ability to give birth naturally. I had an epidural and my son was born quickly. A good outcome, except I felt out of control of the situation.

When I was pregnant again 2 years later, I wanted to give birth in a birth center with a midwife. When I went into preterm labor at 23 weeks, however, I had to transition back to hospital care. Thankfully my son stayed put until 35 weeks. When I went into labor on a Tuesday, I went into the hospital, but again I found myself to be very triggered by everything. My body had the same sort of fear reaction, although to a lesser extent, and we went home.

The next day, I went to the bookstore and read everything I could about natural labor, again. I was doing everything I could to convince myself that I could do it. That I was in control of many things and that I had made great choices: midwives I trusted, a hospital supportive of natural birth, my husband who would be with me, etc. On Thursday, my contractions started again. When we finally checked into the hospital late Thursday night, things slowed down again for a while as I dealt with fear and anxiety. But this time, my midwife was patient, she helped to create a safe environment and respected what I wanted, and no one offered me an epidural. Instead, they offered me lots of other ways to get through labor and I had a great time. I came away from my second labor feeling incredible.

So I don’t know that I would be quick to offer an epidural. For me, the feeling of being forced to lay down and be out of control of so many things was very difficult. I am thankful that the second time around the midwives were awesome about letting me control what I could - wearing my own clothes, listening to my own music, turning off lights, limiting procedures before and after birth, encouraging me to walk around, get in the tub, and try different positions, limiting visitors, limiting monitoring, letting me eat and drink freely, etc.

The only other thing I can suggest in addition to limiting pelvic exams to the bare minimum is to encourage or even insist on an upright birth position. Not only is this a physically and psychologically superior position for any laboring woman, but in her case it will probably help her avoid some very painful memories that can scar her birth memories and potentially stall the labor.

http://nhsblogdoc.blogspot.com/2006/03/vaginal-examinations-in-pregnancy.html

The number of STIs tested for routinely are more limited here: HIV, syphilis and HepB are tested (serology), with follow up culture to confirm syphilis. Other tests aren’t offered routinely, though could be done if there was a particular indication/demand for them (arguably the fact of being pregnant is an indication for them). I guess the situation is very different because of the availability of testing for STIs both through free GP (family doctor) service as well as a free confidential (though underfunded) Genitourinary Medicine service.

How do you test for gonorrhea and chlamydia? There is no bloodwork that can be done for those two STIs, at least not over here, and we do them all the time because they run rampant in our clinic.

And just to restate what I did (and did not) do on this woman: I did a culture for gonorrhea and chlamydia and I did a pap smear. I did NOT do a vaginal exam to assess cervix, a bimanual exam to assess uterus (or poke and prod on a poor traumatized woman), or an exam for pelvimetry.

Routine smear for cervical cell change are done through the national health service screening programme, at the local GP, so no VE would be done for that purpose by a midwife here. In any case, treatment of precancerous cells is not done in pregnancy (will be scheduled for a date after the end of pregnancy) and although the national screening programme advises smears in pregnancy, personally I wonder whether it’s ethical to diagnose what you don’t propose to treat.

Testing for STDs is part of the routine blood tests, so no VE required for that. If the woman complained of vaginal irritation, discharge consistent with a minor infection for which we don’t do a blood test (e.g. thrush) some investigation might be in order (to confirm cause, and prescribe) but otherwise not necessary.

No evidence that doing serial cervical length measurements are protective against preterm labour (especially not in early pregnancy) so no VE would be done for that. If there was a history of preterm labour, that would come up in the initial oral history not on VE, and prompt referral to a doctor for consideration of any preventative measures (unlikely in the UK, unless confirmed cause was cervical incompetence).

If nothing points to PID, no reason to prod her to see if it hurts. And to be honest, I don’t see how you can get an accurate assessment of the PID-associated cervical pain from an examination of someone so traumatised that the entire procedure already hurts.

Fibroids, cysts etc..will show up on the dating ultrasound, so no bimanual exam for those.

The fetal head is the best pelvimeter, so definitely no VE for that purpose - and definitely not bothered here about what type of pelvis she has. Either she’ll have a baby or she won’t, but a VE on the first antenatal visit isn’t going to decide the issue. History of pelvic fracture would come up as part of the oral history taking. If concerns about possible CPD then refer to a doctor and possibly do an MRI if things look ambiguous, but early pregnancy is the wrong time for this - because we don’t know the size of the baby yet.

I think on the other side of the pond, we are perplexed by the number of vaginal examinations done stateside, and the reasons for doing them.

Just to clarify a few things because I don’t think you understood the context of this visit: we also don’t do vaginal exams here unless they’re clinically indicated. However, a vaginal exam at the initial prenatal visit is absolutely clinically indicated for many reasons. We do a speculum exam to check for vaginitis (yeast, BV, trich etc.), test for gonorrhea and chlamydia (because if they have those infections, you’ll certainly want to treat them during the pregnancy), do a pap smear (again, if there’s anything unusual w/ the pap, it’s a good idea to find out sooner rather than later, especially when many of these women don’t get regular paps on an annual basis since many of them don’t have health insurance). We then do a digital VE to assess their cervix (is there cervical motion tenderness–a sign of pelvic inflammatory disease–is their cervix shortened or opening–might they need a sonogram to get a baseline cervical length? Do they have a history of preterm labor or cervical cerclage?). If they’re still in early pregnancy, we also do a bimanual exam to assess for anomalies in the uterus (fibroids, cysts, adnexal masses or tenderness), and then we do clinical pelvimetry to get a sense of their pelvis (gynecoid, android, anthropoid etc., how big was their biggest baby to date, any anomalies in the pelvis from a motor vehicle accident or rickets etc. etc.) And then we’re done.

I have a feeling women in the UK probably receive a similar assessment at their very first prenatal visit too, as part of the standard of care.

In the above case, however, all I did was the test for gonorrhea and chlamydia and then the pap, and that was it. I didn’t do a digital cervical exam or bimanual exam. I felt the STI tests were particularly important given the fact that she had been raped, and perhaps it had been too soon to detect STIs at her exam immediately after the rape.

We do not perform VE’s here in the UK unless they are clinically indicated. Was this woman draining liquor?

Personally, I would not have done a VE on this woman unless she begged me to. It doesn’t sound like she needed one.

In labour, I would be watching for external signs of her dilation. I would probably know when she was coming up to fully. In fact, if you’ve got a very good sense of smell, you can smell when a woman is fully. I would do what I normally do, watch, listen, watch, listen…

…if you are interested in hands-off labour, here is some suggested reading:

Walsh D (2007) Evidence-based Care for Normal Labour and Birth : A guide for midwives Abingdon : Routledge - general mention of loosing the alternative skills

Burville S (2002) Midwifery diagnosis of labour onset British Journal of Midwifery 10 (10) 600:605 - behaviours of labouring women

Lemay G (2005) To push or not? Midwifery Today 74 p 7 - body language

Sutton J (2003) Birth without active pushing and a physiological second stage of labour IN Wickham S ed Midwifery Best Practice Edinburgh: Books for Midwives - rhombus of michaelus

Kitzinger S (2000) Rediscovering Birth Little, Brown and Company : London - jamaican midwives talking of the ‘back opening’ - ie ROM

Bryne D L & Edmonds D K (1990) Clinical method for evaluating progress in the first stage of labour The Lancet 335 (8681) 122 - purple line

Wickham S, Roberts K, Howard J & Waters S (2004) body wisdom ~ smelling birth The Practising Midwife 7 (1) 30 : 31 - smell in room changing

I am a student midwife and a rape survivor. The only thing I can think to say is that it is even more important with trauma survivors to remember that every woman’s experience is different. This woman’s rape may not have been physically painful (I know several women who had that experience) or it might have been the worst pain she has ever felt. That being said offering her a prophylactic epidural as a top tier option *may* come across as “you can’t handle the (normal) pain because you’re damaged” or as “I don’t want to deal with your issues around pain so we just won’t have you feel any.” Or she might be all over that like white on rice. If it were me I’d probably make sure to mention that some women find the disconnect from their bodies to remind them very strongly of the disassociation that can be felt during sexual trauma.

My heart goes out to this woman! And to you for stepping outside a known comfort zone with this. It sounds like you’re doing awesome and are asking good questions.