Post-Scripts: Painful Cervical Exams During Labor

About two weeks ago I posted the first in a new series of "Scripts," or example language to use in common clinical scenarios in midwifery. In the introduction to the first post, I noted that "With these example texts, I seek to provide a springboard for providers, care seekers, and reproductive health workers to discuss possible best practices for language and approach in different scenarios." And goodness did y'all reply! I received loads of lovely feedback, with support and critiques alike for my approach and suggestions. Below I summarize some of the key points. I will include this post-script in the original as well, to show the spectrum of difference in awesome care so many bring to their work. Thanks to everyone for contributing! What an amazing community follows here - I'M the lucky one! I'm already looking forward to the next "Script" and feedback!Note: some have noticed, others not, that I am actively using gender-neutral language in my posts and online. Please consider doing the same when you leave comments! 

...

Here is the original Script on Painful Cervical Exams During Labor

Language

• Try not to make the exam about YOU as a provider: "You're going to feel 'MY' hand on your thigh and on the outside..." and rather say "You're going to feel goopy gel as I separate the labia and then pressure..."

• "Relax your knees out to the side" may include the sexual assault trigger "Relax" for some people, and instead saying "Let your knees fall out to the sides" is likely less triggering.

• Even when someone is in position for the exam, still check in on whether they are ready to begin the exam itself, and reiterate the safe words agreed upon.

• I never say "You're going to feel my touch." As a queer woman, "touch" is a very sexual term. I usually say, "You're going to feel my hand on your thigh, and here on the outside of the vagina."

• Offer for anyone to suggest the language they prefer for their anatomy, not just trans clients.

• Finally, as someone rightly pointed out, this script means there is a heck of a lot of talking in labor! Ideally, this wouldn't be necessary. However, for painful exams, when an update on cervical dilation / effacement / station / consistency / position does inform next steps in supporting physiologic process or induction/augmentation, if this talking not only makes someone more comfortable or provides an appropriate consultation about next steps, I'll do it over as long as needed in between contractions!

Approach

• Invite the person to separate their own labia as an option to decrease pain increase power over the exam

• Minimize any other interventions/interactions happening at the same time (intake questions from the RN, BP cuff inflating, adjusting monitors, family calling others, etc.)

• Check-in throughout the exam: if muscles tense, if the laborer closes their eyes, if their breathing changes... ask how they are feeling, continue discussing what your exam is finding, and offering opportunities to relax muscles and wait until they're ready to continue.

• When I begin the exam, I touch someone's thigh, and then touch again on the outside of their labia: two separate touches. The "thigh slide," as one gynecologic teaching associate (GTA) called it in the comments page, or touching the thigh and sliding up to the labia, is too akin to intimate touching, and should be avoided.

• Multiple readers suggested offering the examiner's non-dominant hand for the client to hold or grasp as another form of communicating discomfort or expressing a need to rest/stop.

• For a very posterior cervix or posterior discomfort during exams, consider placing something underneath the sacrum (upside-down bed pan, rolled blankets/towels) to change the position of the pelvic floor and uterus/cervix to be easier to reach. I rarely offer to use the person's own hands (in fists) to reach this goal, since having hands pinned behind one's back can be disempowering/triggering/difficult to change other body positions when shoulders/arms are in that position.

• Importantly, only discuss/offer cervical exams when absolutely necessary. I touched on this a bit in the original post, but someone pointed out how over-done and unnecessary these exams often are in labor. Always consider what information is gained from the exam, and whether or not it changes the plan!

Thanks again for all the feedback! Now to get to work on the next script (suggestions welcomed)!

- Stephanie